Provider Demographics
NPI:1740777093
Name:BRECKON, TAMARA
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:BRECKON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 SW 125 ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:IL
Mailing Address - Zip Code:62016-2009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1515 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650
Practice Address - Country:US
Practice Address - Phone:217-243-6454
Practice Address - Fax:217-243-1388
Is Sole Proprietor?:No
Enumeration Date:2018-04-21
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017135363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily