Provider Demographics
NPI:1356337224
Name:VALENTINE, TINA LOUISE (CNP)
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:LOUISE
Last Name:VALENTINE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 PRAIRIE VIEW EST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-3336
Mailing Address - Country:US
Mailing Address - Phone:618-476-7870
Mailing Address - Fax:618-476-7853
Practice Address - Street 1:421 S MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-2460
Practice Address - Country:US
Practice Address - Phone:618-281-7151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO106770363L00000X
IL209-001032363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP13603Medicare UPIN