Individual
PAULA R ICENOGLE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
708 SHERRY ST, COLCHESTER, IL 62326-1176
(309) 776-3978
Mailing address
708 SHERRY ST, COLCHESTER, IL 62326-1176
(309) 776-3978
Taxonomy
Speciality
Code
Description
License number
State
172A00000X
Driver
Primary
I25267678827
IL
Other
Enumeration date
04/13/2008
Last updated
04/13/2008
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