Provider Demographics
NPI:1629354519
Name:MASSEY, GINA (APN)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:MASSEY
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 1:403 E. 1ST STREET
Mailing Address - Street 2:KATHERINE SHAW BETHEA HOSPITAL
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021
Mailing Address - Country:US
Mailing Address - Phone:815-285-5629
Mailing Address - Fax:815-285-5634
Practice Address - Street 1:403 E. 1ST STREET
Practice Address - Street 2:KATHERINE SHAW BETHEA HOSPITAL
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021
Practice Address - Country:US
Practice Address - Phone:815-285-5629
Practice Address - Fax:815-285-5634
Is Sole Proprietor?:No
Enumeration Date:2011-10-24
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.009085363L00000X
IL209009085363LF0000X
NV832274363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209009085Medicaid
ILF400097873Medicare PIN