Provider Demographics
NPI:1053734004
Name:WITHERSPOON, FABIENNE NADEEN (NP-C)
Entity type:Individual
Prefix:MS
First Name:FABIENNE
Middle Name:NADEEN
Last Name:WITHERSPOON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:IL
Mailing Address - Zip Code:61846-1440
Mailing Address - Country:US
Mailing Address - Phone:217-274-6966
Mailing Address - Fax:217-601-2133
Practice Address - Street 1:712 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:IL
Practice Address - Zip Code:61846-1440
Practice Address - Country:US
Practice Address - Phone:217-274-6966
Practice Address - Fax:217-601-2133
Is Sole Proprietor?:No
Enumeration Date:2014-01-28
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009867363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily