Provider Demographics
NPI:1023560067
Name:SUSTE, KAYLYNN (NP)
Entity Type:Individual
Prefix:
First Name:KAYLYNN
Middle Name:
Last Name:SUSTE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:725 SCHOOL ST STE A
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-1207
Mailing Address - Country:US
Mailing Address - Phone:815-941-9124
Mailing Address - Fax:815-941-4363
Practice Address - Street 1:1450 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:DIAMOND
Practice Address - State:IL
Practice Address - Zip Code:60416-6050
Practice Address - Country:US
Practice Address - Phone:815-634-3500
Practice Address - Fax:815-705-1718
Is Sole Proprietor?:No
Enumeration Date:2016-10-25
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015024363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID209.015024OtherLICENSE