Provider Demographics
NPI:1578258877
Name:VON DER VELLEN, GINA (APRN, CPNP)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:VON DER VELLEN
Suffix:
Gender:F
Credentials:APRN, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 HARDING RD # 303F
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-9318
Mailing Address - Country:US
Mailing Address - Phone:330-714-6729
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:61637-2639
Practice Address - Country:US
Practice Address - Phone:309-624-9688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-11
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041566358163W00000X
OHRN.451803163WP0200X
IL209029829363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
No163WP0200XNursing Service ProvidersRegistered NursePediatrics