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DEACONESS IL SPECIALTY EXPRESS BROADWAY ST
NPI 1497462964
Nurse Practitioner in Mount Vernon, IL

Active since November 03, 2022CLIA 14D2270655 · Waiver
3111 BROADWAY ST, MOUNT VERNON, IL 62864(618) 241-0300(618) 241-0302 Get Directions Write a Review

NPPES record last updated: January 26, 2023. Verified against the NPPES registry weekly; last sync: August 09, 2026.

Record update history: Jan 26, 2023, Dec 2, 2022, Nov 9, 2022 and 1 more (4 updates tracked since 2022).

About Deaconess Il Specialty Express Broadway St NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

DEACONESS IL SPECIALTY EXPRESS BROADWAY ST (NPI 1497462964) is a healthcare organization registered as a nurse practitioner in Mount Vernon, Illinois and active in the NPI registry since November 2022. The organization holds a CLIA Waiver certificate valid through October 18, 2026 and lists Kyle Dillman, Secretary Treasurer, as its authorized official.

NPPES Registry Identity

NPI1497462964
Entity TypeOrganization
Primary Taxonomy363L00000X
Legal Business NameDEACONESS ILLINOIS SPECIALTY CLINIC, INC.
Location Address3111 BROADWAY STMount Vernon, IL 62864-2338
Mailing AddressPo Box 34266Belfast, ME 04915-0620 · (812) 450-6815 · Fax (812) 450-6822
Phone(618) 241-0300
Fax(618) 241-0302
Organization SubpartNo
Authorized OfficialKyle DillmanSecretary Treasurer · (812) 450-7399
Enumeration DateNovember 3, 2022
Last NPPES UpdateJanuary 26, 20234 updates tracked since enumeration
NPPES CertifiedJanuary 26, 2023
✔ NPI 1497462964 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses 2

★ Primary SpecialtyNurse PractitionerPhysician Assistants & Advanced Practice Nursing Providers
Taxonomy Code363L00000X
Definition
(1) A registered nurse provider with a graduate degree in nursing prepared for advanced practice involving independent and interdependent decision making and direct accountability for clinical judgment across the health care continuum or in a certified specialty. (2) A registered nurse who has completed additional training beyond basic nursing education and who provides primary health care services in accordance with state nurse practice laws or statutes. Tasks performed by nurse practitioners vary with practice requirements mandated by geographic, political, economic, and social factors. Nurse practitioner specialists include, but are not limited to, family nurse practitioners, gerontological nurse practitioners, pediatric nurse practitioners, obstetric-gynecologic nurse practitioners, and school nurse practitioners.
Also ListedFamily Medicine · Sports MedicineTaxonomy 207QS0010X
3111 BROADWAY ST, Mount Vernon, IL 62864
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Other Names 1

Doing Business AsDeaconess Il Specialty Express Broadway St

Group Practice 1

Group TaxonomyThis provider is a business group of one or more individual practitioners, who practice with different areas of specialization.193200000X MULTI-SPECIALTY GROUP

CLIA Laboratory Certificates CMS CLIA

Laboratory certificates issued under the Clinical Laboratory Improvement Amendments (CLIA) program, which sets federal quality standards for human laboratory testing in the United States. There is no official CMS crosswalk between CLIA and NPI numbers; these certificates are associated with this NPI by matching facility names, locations and phone numbers in the CMS CLIA registry.

Certificate of Waiver 14D2270655

Deaconess Illinois Specialty Clinic Express · Mount Vernon, IL
Active · expires Oct 18, 2026
CLIA Number14D2270655
Laboratory TypePhysician Office
Certificate Effective DateOctober 19, 2024
Certificate Expiration DateOctober 18, 2026
Laboratory DirectorAmber Bruce
Laboratory Phone(618) 241-0300
Laboratory LocationDeaconess Illinois Specialty Clinic Express3111 Broadway St, Mount Vernon, IL 62864
CLIA data matches this NPI record on: Address Name Phone
This certificate is issued to a laboratory to perform only waived tests.

Other Providers at the Same Location NPPES 4

Providers registered at the same practice address, or within the immediate area, according to the NPPES registry.

DEACONESS ILLINOIS CLINIC, INC
Family Medicine
3111 BROADWAY ST
MOUNT VERNON, IL 62864
Jefferson County (618) 241-0300
DEACONESS ILLINOIS SPECIALTY CLINIC, INC.
Nurse Practitioner (Occupational Health)
3111 BROADWAY ST
MOUNT VERNON, IL 62864
Jefferson County (618) 241-0333
BRIDGETT NICOLE BROWN FNP-C
Nurse Practitioner
3111 BROADWAY ST
MOUNT VERNON, IL 62864
Jefferson County (618) 241-0333
BRITTANY MCDONALD APRN
Nurse Practitioner
3111 BROADWAY ST
MOUNT VERNON, IL 62864
Jefferson County (618) 241-0300

Frequently Asked Questions NPPES & CMS

Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.

What is Deaconess Illinois Specialty Clinic, Inc.'s NPI number?

The NPI number for Deaconess Illinois Specialty Clinic, Inc. is 1497462964. It was assigned to this organization in the NPPES registry on November 3, 2022. The provider is doing business as Deaconess Il Specialty Express Broadway St.

Where is Deaconess Illinois Specialty Clinic, Inc. located?

Deaconess Illinois Specialty Clinic, Inc. is located at 3111 Broadway St, Mount Vernon, IL 62864. The listed phone number is (618) 241-0300.

What is Deaconess Illinois Specialty Clinic, Inc.'s specialty?

The primary specialty registered for this NPI is Nurse Practitioner with taxonomy code 363L00000X.

Does Deaconess Illinois Specialty Clinic, Inc. hold a CLIA laboratory certificate?

Yes. A Certificate of Waiver (number 14D2270655) is associated with this NPI, valid through October 18, 2026. CLIA certificates authorize laboratory testing under the federal Clinical Laboratory Improvement Amendments program.

When was this NPI record last updated?

The NPPES record for Deaconess Illinois Specialty Clinic, Inc. was last updated on January 26, 2023. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 3 years ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.