Basic Information
| Provider Information | |||||||||
| NPI: | 1063818094 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HECKENKAMP | ||||||||
| FirstName: | MADELEINE | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ACNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | O'DONNELL | ||||||||
| OtherFirstName: | MADELEINE | ||||||||
| OtherMiddleName: | D | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 3428 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627083428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005775368 | ||||||||
| FaxNumber: | 2177572021 | ||||||||
| Practice Location | |||||||||
| Address1: | 3132 OLD JACKSONVILLE RD | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627047400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175882600 | ||||||||
| FaxNumber: | 2178620904 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2014 | ||||||||
| LastUpdateDate: | 01/04/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 209012212 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 209012212 | 01 | IL | APN LICENSE | OTHER |