Provider Demographics
NPI:1881639235
Name:WIEBKE, NANCY (APRN)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:WIEBKE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:THREE ST. ELIZABETH'S BLVD.
Mailing Address - Street 2:STE. 2800
Mailing Address - City:O'FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1099
Mailing Address - Country:US
Mailing Address - Phone:618-233-6044
Mailing Address - Fax:833-973-4218
Practice Address - Street 1:THREE ST. ELIZABETH'S BLVD.
Practice Address - Street 2:STE. 2800
Practice Address - City:O'FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1099
Practice Address - Country:US
Practice Address - Phone:618-233-6044
Practice Address - Fax:833-973-4218
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.000757207RC0000X
IL209000757363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
101174OtherHEALTH ALLIANCE
478882OtherHEALTHLINK
500020298OtherRR MEDICARE
P38294OtherMERCY
478882OtherHEALTHLINK
478882OtherHEALTHLINK
ILK45078Medicare PIN
ILF400249763Medicare PIN
IL596500019Medicare PIN