Provider Demographics
NPI:1679225940
Name:MCCAMY, PATHERESA A (LPN)
Entity Type:Individual
Prefix:
First Name:PATHERESA
Middle Name:A
Last Name:MCCAMY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 SABRINA DR UNIT C
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-3582
Mailing Address - Country:US
Mailing Address - Phone:309-699-9700
Mailing Address - Fax:309-699-2937
Practice Address - Street 1:731 SABRINA DR UNIT C
Practice Address - Street 2:
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611-3582
Practice Address - Country:US
Practice Address - Phone:309-699-9700
Practice Address - Fax:309-699-2937
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-19
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043129490164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty