Provider Demographics
NPI:1679153456
Name:BANCROFT, NATASHA D (AGACNP)
Entity Type:Individual
Prefix:MS
First Name:NATASHA
Middle Name:D
Last Name:BANCROFT
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18846 N HAILS LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-8312
Mailing Address - Country:US
Mailing Address - Phone:618-237-2309
Mailing Address - Fax:
Practice Address - Street 1:18846 N HAILS LN
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-8312
Practice Address - Country:US
Practice Address - Phone:618-237-2309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-14
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209022987363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology