Provider Demographics
NPI:1457730046
Name:WILMERT, DOREEN A (FNP-BC)
Entity Type:Individual
Prefix:
First Name:DOREEN
Middle Name:A
Last Name:WILMERT
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:DOREEN
Other - Middle Name:A
Other - Last Name:FOX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:520 N 4TH ST
Mailing Address - Street 2:PO BOX 19670
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-5238
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-747-1351
Practice Address - Street 1:520 N 4TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5238
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-747-1351
Is Sole Proprietor?:No
Enumeration Date:2015-05-28
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-012667363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
IL$$$$$$$$$001Medicaid