Provider Demographics
NPI:1508237744
Name:RAITHEL, DEENA R (APN)
Entity Type:Individual
Prefix:
First Name:DEENA
Middle Name:R
Last Name:RAITHEL
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E PENNSYLVANIA AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3045
Mailing Address - Country:US
Mailing Address - Phone:309-655-7888
Mailing Address - Fax:309-655-7905
Practice Address - Street 1:200 E PENNSYLVANIA AVE STE 105
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3045
Practice Address - Country:US
Practice Address - Phone:309-655-7888
Practice Address - Fax:309-655-7905
Is Sole Proprietor?:No
Enumeration Date:2015-10-14
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-013127363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner