Provider Demographics
NPI:1790496099
Name:SYMATREE LLC
Entity Type:Organization
Organization Name:SYMATREE LLC
Other - Org Name:SYMATREE LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:RUSHING
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:217-904-3035
Mailing Address - Street 1:495 DEVONSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-7295
Mailing Address - Country:US
Mailing Address - Phone:217-904-3035
Mailing Address - Fax:
Practice Address - Street 1:411 DEVONSHIRE DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7286
Practice Address - Country:US
Practice Address - Phone:217-714-8912
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-07
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400103582Medicaid