Provider Demographics
NPI:1356450142
Name:PUTNAM, ABBY A (CFNP)
Entity type:Individual
Prefix:
First Name:ABBY
Middle Name:A
Last Name:PUTNAM
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:IL
Mailing Address - Zip Code:61520-2608
Mailing Address - Country:US
Mailing Address - Phone:309-647-0201
Mailing Address - Fax:309-649-5302
Practice Address - Street 1:180 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-2608
Practice Address - Country:US
Practice Address - Phone:309-647-0201
Practice Address - Fax:309-649-6880
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041315919363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02922981OtherBCBS
IL041315919Medicaid
IL107762OtherHEALTH ALLIANCE
IL0062839OtherUMWA
IL1942315197OtherNPI CLINIC NUMBER
IL107762OtherHEALTH ALLIANCE
ILQ43364Medicare UPIN
IL041315919Medicaid
IL0062839OtherUMWA
IL545970Medicare ID - Type UnspecifiedMEDICARE GROUP
ILCG5172Medicare ID - Type UnspecifiedRR MEDICARE GROUP