Jennifer Renee Stoller, DNP, PNP-PC
Individual provider Active NPI Pediatric Nurse Practitioner · Roanoke, IL
NPI 1154035913 · NPPES record last updated Jan 6, 2023
Key facts
- NPI
- 1154035913
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Pediatric Nurse Practitioner 363LP0200X
- License
- 209.025987 (IL)
- Practice address
- 401 N Main St
Roanoke, IL 61561-7585 - Phone
- (309) 923-2661
- NPI assigned
- Jan 6, 2023
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 2
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IL
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20230330002150 | IL | Practitioner - Nurse Practitioner | 7315312501 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Nurse Practitioner
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 209.025987 | IL | MD | Pediatric Nurse Practitioner |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Osf Multi-Specialty Group | Current |
Accepting new patients | |
| Central PA Pharmacy LLC. | Current | Accepting new patients |
Locations
8600 State Route 91
Ste 130
Peoria, IL 61615
Phone (309) 683-5050
1420 W Pioneer Pkwy
Peoria, IL 61615
Phone (309) 308-5195
2806 N Knoxville Ave
Peoria, IL 61604
Phone (309) 655-6961
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatric Nurse Practitioner | 363LP0200X | 209.025987 | IL | Yes |
Addresses
Primary practice location
401 N Main St
Roanoke, IL 61561-7585
Mailing address
364 Macallen Lake Rd
Carlock, IL 61725-9032
Phone (309) 657-7918
Other providers in Roanoke, IL
- Roanoke RX LLC
- Marsha Alexandra Rodriguez
- Saint James Hospital
- Michelle M Stephens
- Brad A. Stoecker
- Erica Nicole Svendsen
- Victory Home Care Services, Inc.
- Tracy Jo Walker
- Jillian L Wignes
- Casey David Williams
All providers in Roanoke, IL · Pediatric Nurse Practitioner in Illinois
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 6, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.