Provider Demographics
NPI:1699761726
Name:WILLEMSEN-DUNLAP, ANN M (CRNA)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:M
Last Name:WILLEMSEN-DUNLAP
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8600 STATE ROUTE 91 STE 250
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-7831
Mailing Address - Country:US
Mailing Address - Phone:309-692-5394
Mailing Address - Fax:309-692-2538
Practice Address - Street 1:8600 STATE ROUTE 91 STE 250
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-7831
Practice Address - Country:US
Practice Address - Phone:309-692-5394
Practice Address - Fax:309-692-2538
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAD079522367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA44812OtherWELLMARK BCBS
IA0172700Medicaid
IA0172700Medicaid
S57372Medicare UPIN
IA430053222Medicare PIN