Provider Demographics
NPI:1952847634
Name:WASHUM, IVA (LPN)
Entity Type:Individual
Prefix:
First Name:IVA
Middle Name:
Last Name:WASHUM
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 FULTON ST
Mailing Address - Street 2:SUITE 207
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61602-1347
Mailing Address - Country:US
Mailing Address - Phone:309-671-8700
Mailing Address - Fax:
Practice Address - Street 1:211 FULTON ST
Practice Address - Street 2:STE 207
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-1347
Practice Address - Country:US
Practice Address - Phone:309-671-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043052637164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse