Individual
CONNIE H REQUARTH
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
APN
Contact information
Practice address
2905 NORTH MAIN STREET, DECATUR, IL 62526-4274
(217) 877-9117
(217) 877-3078
Mailing address
2905 NORTH MAIN STREET, DECATUR, IL 62526-4274
(217) 877-9117
(217) 877-3082
Taxonomy
Speciality
Code
Description
License number
State
363LW0102X
Women's Health Nurse Practitioner
Primary
041135327
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
P00238267
MEDICARE RR
IL
Enumeration date
08/08/2006
Last updated
11/28/2011
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