Provider Demographics
NPI:1467462085
Name:REQUARTH, CONNIE H (APN)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:H
Last Name:REQUARTH
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2905 NORTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-4274
Mailing Address - Country:US
Mailing Address - Phone:217-877-9117
Mailing Address - Fax:217-877-3082
Practice Address - Street 1:2905 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4274
Practice Address - Country:US
Practice Address - Phone:217-877-9117
Practice Address - Fax:217-877-3078
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041135327363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00238267OtherMEDICARE RR
ILP00238267OtherMEDICARE RR
ILK13761Medicare PIN