Provider Demographics
NPI:1366819971
Name:MOUNCE, MICHELE LYNN (CNP)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:LYNN
Last Name:MOUNCE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:LYNN
Other - Last Name:CUSACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:125 HEATHERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611
Mailing Address - Country:US
Mailing Address - Phone:309-655-3000
Mailing Address - Fax:
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-0001
Practice Address - Country:US
Practice Address - Phone:309-655-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-31
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61333948363L00000X
IL209.012995363LA2100X
IL209012995363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care