Provider Demographics
NPI:1902276207
Name:EETEN, LYNETTE (APN)
Entity Type:Individual
Prefix:
First Name:LYNETTE
Middle Name:
Last Name:EETEN
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:LYNETTE
Other - Middle Name:
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:180 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:IL
Mailing Address - Zip Code:61520-2608
Mailing Address - Country:US
Mailing Address - Phone:309-647-0201
Mailing Address - Fax:309-649-5101
Practice Address - Street 1:180 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-2608
Practice Address - Country:US
Practice Address - Phone:309-647-0201
Practice Address - Fax:309-649-6880
Is Sole Proprietor?:No
Enumeration Date:2015-09-29
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.013158363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209.013158OtherLICENSE