Individual
MR. BRENTON WAYSTOUT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
FNP-BC
Contact information
Practice address
115 E WALNUT ST, FAIRBURY, IL 61739
(815) 692-2305
Mailing address
115 E WALNUT ST, FAIRBURY, IL 61739-1516
(815) 692-2305
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
209011651
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
209011651
LICENSE
IL
Enumeration date
07/16/2014
Last updated
05/17/2018
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