Provider Demographics
NPI:1013639376
Name:FIFE, CASSANDRA (APRN)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:FIFE
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 1:6 WESTPORT CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-8233
Mailing Address - Country:US
Mailing Address - Phone:309-722-4020
Mailing Address - Fax:309-740-4440
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?:No
Enumeration Date:2022-09-14
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2090258848367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209025884OtherADVANCED PRACTICE REGISTERED NURSE LICENSE