Provider Demographics
NPI:1336619782
Name:FARAONE, MINDY MARIE (FNP)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:MARIE
Last Name:FARAONE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 MEMORIAL DR STE 230B
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6705
Mailing Address - Country:US
Mailing Address - Phone:636-344-2014
Mailing Address - Fax:
Practice Address - Street 1:4 MEMORIAL DR STE 230B
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6705
Practice Address - Country:US
Practice Address - Phone:636-344-2014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-28
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018035985363L00000X, 363LF0000X
IL209018555363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner