Provider Demographics
NPI:1063515385
Name:MUICH, SALLY JANE (NP)
Entity type:Individual
Prefix:MS
First Name:SALLY
Middle Name:JANE
Last Name:MUICH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:JANE
Other - Last Name:MUICH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSN, APRN
Mailing Address - Street 1:180 S 3RD ST
Mailing Address - Street 2:300
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-1952
Mailing Address - Country:US
Mailing Address - Phone:618-233-5480
Mailing Address - Fax:618-222-4972
Practice Address - Street 1:180 S 3RD ST
Practice Address - Street 2:300
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1952
Practice Address - Country:US
Practice Address - Phone:618-233-5480
Practice Address - Fax:618-222-4972
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO099684163WG0600X
IL209006132363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163WG0600XNursing Service ProvidersRegistered NurseGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP68319Medicare UPIN