Provider Demographics
NPI:1255748745
Name:WAYSTOUT, BRENTON (FNP-BC)
Entity type:Individual
Prefix:MR
First Name:BRENTON
Middle Name:
Last Name:WAYSTOUT
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:MR
Other - First Name:BRENTON
Other - Middle Name:M
Other - Last Name:KNEER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:115 E WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBURY
Mailing Address - State:IL
Mailing Address - Zip Code:61739-1516
Mailing Address - Country:US
Mailing Address - Phone:815-692-2305
Mailing Address - Fax:
Practice Address - Street 1:115 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:FAIRBURY
Practice Address - State:IL
Practice Address - Zip Code:61739
Practice Address - Country:US
Practice Address - Phone:815-692-2305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-16
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209011651363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209011651OtherLICENSE