Provider Demographics
NPI:1700823556
Name:WISSLER, SHARON R (CNP)
Entity Type:Individual
Prefix:MS
First Name:SHARON
Middle Name:R
Last Name:WISSLER
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1506 W REYNOLDS ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764
Mailing Address - Country:US
Mailing Address - Phone:815-844-6123
Mailing Address - Fax:815-884-7851
Practice Address - Street 1:1506 W REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764
Practice Address - Country:US
Practice Address - Phone:815-844-6123
Practice Address - Fax:815-884-7851
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209004260363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05732097OtherBCBS GROUP NUMBER
IL085507OtherHEALTH ALLIANCE
833230OtherMEDICARE GROUP #
IL085507OtherHEALTH ALLIANCE
ILP00282414Medicare ID - Type UnspecifiedRR MEDICARE
833230012Medicare PIN
K23127Medicare ID - Type Unspecified
IL05732097OtherBCBS GROUP NUMBER