Provider Demographics
NPI:1649414558
Name:SOBCZAK, BERNADETTE KATHLENE (CPNP PRIMARY CAR)
Entity Type:Individual
Prefix:MRS
First Name:BERNADETTE
Middle Name:KATHLENE
Last Name:SOBCZAK
Suffix:
Gender:F
Credentials:CPNP PRIMARY CAR
Other - Prefix:
Other - First Name:BERNADETTE
Other - Middle Name:KATHLENE
Other - Last Name:MORDIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:807 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GILLESPIE
Mailing Address - State:IL
Mailing Address - Zip Code:62033
Mailing Address - Country:US
Mailing Address - Phone:217-839-3900
Mailing Address - Fax:217-839-1313
Practice Address - Street 1:807 BROADWAY
Practice Address - Street 2:
Practice Address - City:GILLESPIE
Practice Address - State:IL
Practice Address - Zip Code:62033
Practice Address - Country:US
Practice Address - Phone:217-839-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-22
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-007531363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics