Provider Demographics
NPI:1255052254
Name:INEZA, JEANNETTE
Entity type:Individual
Prefix:
First Name:JEANNETTE
Middle Name:
Last Name:INEZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4157
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79704-4157
Mailing Address - Country:US
Mailing Address - Phone:269-823-2321
Mailing Address - Fax:
Practice Address - Street 1:400 ROSALIND REDFERN GROVER PWY
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62026-0001
Practice Address - Country:US
Practice Address - Phone:432-699-0306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-07
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041488084163W00000X
TX1116055367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse