Provider Demographics
NPI:1447580774
Name:FORSYTHE, JAMIE L (NP)
Entity Type:Individual
Prefix:MS
First Name:JAMIE
Middle Name:L
Last Name:FORSYTHE
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:217-383-4752
Practice Address - Street 1:200 LERNA RD S
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-9388
Practice Address - Country:US
Practice Address - Phone:217-258-5900
Practice Address - Fax:217-258-3686
Is Sole Proprietor?:No
Enumeration Date:2010-01-08
Last Update Date:2013-08-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL209007210363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208905183Medicare PIN