Provider Demographics
NPI:1134547367
Name:WOMACK, CINDY LEE (FNP-BC)
Entity type:Individual
Prefix:
First Name:CINDY
Middle Name:LEE
Last Name:WOMACK
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:CINDY
Other - Middle Name:LEE
Other - Last Name:BUCKLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:751 N RUTLEDGE ST
Mailing Address - Street 2:P.O. BOX 19643
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-4968
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-7363
Practice Address - Street 1:751 N RUTLEDGE ST
Practice Address - Street 2:SUITE 3100
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4968
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-7363
Is Sole Proprietor?:No
Enumeration Date:2014-04-04
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.011374363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
ILF400134427Medicare PIN