Provider Demographics
NPI:1184710402
Name:BUSHUR, VICKIE SUE (FNP-BC)
Entity type:Individual
Prefix:
First Name:VICKIE
Middle Name:SUE
Last Name:BUSHUR
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-2403
Mailing Address - Country:US
Mailing Address - Phone:217-528-7541
Mailing Address - Fax:
Practice Address - Street 1:300 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-2003
Practice Address - Country:US
Practice Address - Phone:217-342-4151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209005665363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ62438Medicare UPIN
IL148997Medicare Oscar/Certification
K24770Medicare PIN
IL1952304412OtherGRP NPI #
IL37-1329873OtherCORP TAX ID
ILQ62438Medicare UPIN
IL148997Medicare Oscar/Certification
IL1205023637OtherGRP RHC NPI #
IL210756OtherGRP MEDICARE #