Provider Demographics
NPI:1467890657
Name:BILDERBACK, CODY E (FNP)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:E
Last Name:BILDERBACK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:CODY
Other - Middle Name:E
Other - Last Name:BASCIANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:4 MEMORIAL DR STE 230B
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6705
Mailing Address - Country:US
Mailing Address - Phone:618-463-7874
Mailing Address - Fax:
Practice Address - Street 1:4 MEMORIAL DR STE 230B
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6705
Practice Address - Country:US
Practice Address - Phone:618-463-7874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-10
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013012822363LF0000X
IL209010451363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2013012822OtherMO LICENSE