Provider Demographics
NPI:1083242044
Name:SYKES, KORETTA G
Entity Type:Individual
Prefix:
First Name:KORETTA
Middle Name:G
Last Name:SYKES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 ELM ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-3535
Mailing Address - Country:US
Mailing Address - Phone:217-617-6964
Mailing Address - Fax:
Practice Address - Street 1:1517 S 12TH ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-6759
Practice Address - Country:US
Practice Address - Phone:217-228-1974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-27
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3336237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty