Provider Demographics
NPI:1619640612
Name:VANBLARICUM, SALLIE ANNE (APN)
Entity Type:Individual
Prefix:
First Name:SALLIE
Middle Name:ANNE
Last Name:VANBLARICUM
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:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822-0155
Mailing Address - Country:US
Mailing Address - Phone:618-724-1633
Mailing Address - Fax:618-724-4628
Practice Address - Street 1:165 KINNAMAN DR
Practice Address - Street 2:
Practice Address - City:FLORA
Practice Address - State:IL
Practice Address - Zip Code:62839-4204
Practice Address - Country:US
Practice Address - Phone:618-662-8386
Practice Address - Fax:618-662-4338
Is Sole Proprietor?:No
Enumeration Date:2021-07-27
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209023417363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily