Provider Demographics
NPI:1871043703
Name:FRISBIE, DEIDRA (FNP-C)
Entity Type:Individual
Prefix:
First Name:DEIDRA
Middle Name:
Last Name:FRISBIE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 N 9TH ST
Mailing Address - Street 2:PO BOX 19635
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-5303
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-8115
Practice Address - Street 1:415 N 9TH ST
Practice Address - Street 2:SUITE 2W94
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5303
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-8115
Is Sole Proprietor?:No
Enumeration Date:2016-10-04
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209014831363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
ILF400344155Medicare PIN