Provider Demographics
NPI:1821134115
Name:BOEHNING, AGNES (APN-FNP)
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:
Last Name:BOEHNING
Suffix:
Gender:F
Credentials:APN-FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4117 S WATER TOWER PL
Mailing Address - Street 2:SUITE D
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6567
Mailing Address - Country:US
Mailing Address - Phone:618-242-4848
Mailing Address - Fax:618-242-4198
Practice Address - Street 1:819 E MCCORD ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3044
Practice Address - Country:US
Practice Address - Phone:618-533-1313
Practice Address - Fax:618-533-3711
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209003194363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209003194OtherLICENSE