Provider Demographics
NPI:1932510203
Name:WIERENGA, TRISHA (BSN, RN, IBCLC, RLC)
Entity Type:Individual
Prefix:
First Name:TRISHA
Middle Name:
Last Name:WIERENGA
Suffix:
Gender:F
Credentials:BSN, RN, IBCLC, RLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2016 MARSHALL RD
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:IL
Mailing Address - Zip Code:61530-1627
Mailing Address - Country:US
Mailing Address - Phone:309-370-4025
Mailing Address - Fax:
Practice Address - Street 1:6 WESTPORT CT
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-8233
Practice Address - Country:US
Practice Address - Phone:309-722-4020
Practice Address - Fax:309-740-4440
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-08
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILL-35463163WL0100X
IL209023427363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209023427OtherFAMILY NURSE PRACTITIONER