Provider Demographics
NPI:1720421175
Name:MIDDENDORF, JENNIFER SHINE (ANP-C)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:SHINE
Last Name:MIDDENDORF
Suffix:
Gender:F
Credentials:ANP-C
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Mailing Address - Street 1:1 BRONZE POINTE BLVD STE 1A
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-1045
Mailing Address - Country:US
Mailing Address - Phone:618-233-7055
Mailing Address - Fax:618-233-9055
Practice Address - Street 1:1 BRONZE POINTE BLVD STE 1A
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-1045
Practice Address - Country:US
Practice Address - Phone:618-233-7055
Practice Address - Fax:618-233-9055
Is Sole Proprietor?:No
Enumeration Date:2013-04-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2013009799363L00000X
IL209010646363LA2200X, 207LP2900X, 363L00000X
MO2004030088163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILMA5045004Medicare PIN
IL621825612Medicaid