Provider Demographics
NPI:1295169324
Name:NORDSTROM, ANNETTA MARIE (APN, NP-C)
Entity type:Individual
Prefix:MRS
First Name:ANNETTA
Middle Name:MARIE
Last Name:NORDSTROM
Suffix:
Gender:F
Credentials:APN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 N COLLEGE AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:GENESEO
Mailing Address - State:IL
Mailing Address - Zip Code:61254-1092
Mailing Address - Country:US
Mailing Address - Phone:309-944-5342
Mailing Address - Fax:309-944-8192
Practice Address - Street 1:600 N COLLEGE AVE STE 120
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:IL
Practice Address - Zip Code:61254-1092
Practice Address - Country:US
Practice Address - Phone:309-944-5342
Practice Address - Fax:309-944-8192
Is Sole Proprietor?:No
Enumeration Date:2013-08-26
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.010672363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily