Provider Demographics
NPI:1407408149
Name:MOSLEY, JEANETTE T (APN)
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:T
Last Name:MOSLEY
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 1:111 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:STREATOR
Mailing Address - State:IL
Mailing Address - Zip Code:61364-3332
Mailing Address - Country:US
Mailing Address - Phone:815-672-4587
Mailing Address - Fax:815-673-3582
Practice Address - Street 1:111 SPRING ST
Practice Address - Street 2:
Practice Address - City:STREATOR
Practice Address - State:IL
Practice Address - Zip Code:61364-3332
Practice Address - Country:US
Practice Address - Phone:815-672-4587
Practice Address - Fax:815-673-3582
Is Sole Proprietor?:No
Enumeration Date:2019-07-12
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209019071363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner