Provider Demographics
NPI:1518218361
Name:NESEMEIER, MINDY (NP)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:
Last Name:NESEMEIER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:IL
Mailing Address - Zip Code:61061-1001
Mailing Address - Country:US
Mailing Address - Phone:815-732-3151
Mailing Address - Fax:815-732-3718
Practice Address - Street 1:1307 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:IL
Practice Address - Zip Code:61061
Practice Address - Country:US
Practice Address - Phone:815-732-3151
Practice Address - Fax:815-732-3718
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009778363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL381220034OtherMEDICARE
IL$$$$$$$$$001Medicaid