Provider Demographics
NPI:1720165103
Name:COBURN, BONNIE JEAN (NP)
Entity Type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:JEAN
Last Name:COBURN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 N EDWARD ST STE 6102
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-4163
Mailing Address - Country:US
Mailing Address - Phone:217-876-6456
Mailing Address - Fax:217-876-6485
Practice Address - Street 1:4455 E US ROUTE 36
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-5003
Practice Address - Country:US
Practice Address - Phone:217-588-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209006142363L00000X
IL277000529363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041292879Medicaid
IL036102377 1Medicaid
IL433990OtherMEDICARE GROUP
IL1497762959 1Medicaid
ILP00678744OtherRAILROAD MEDICARE
ILP00678744OtherRAILROAD MEDICARE
Q72395Medicare UPIN
R01055Medicare PIN
IL433990OtherMEDICARE GROUP
IL041292879Medicaid