Provider Demographics
NPI:1497020234
Name:HATHCOCK, VIRGINIA KATHERINE HOUSE (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:VIRGINIA
Middle Name:KATHERINE HOUSE
Last Name:HATHCOCK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:
Practice Address - Street 1:4789 ROUTE 71
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-7415
Practice Address - Country:US
Practice Address - Phone:630-692-5730
Practice Address - Fax:630-692-5731
Is Sole Proprietor?:No
Enumeration Date:2012-03-13
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-121553363LF0000X
IL209.011936363LF0000X
IL209011936363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily