Provider Demographics
NPI:1164723656
Name:PRULLAGE, GERALYN SUE (APN)
Entity Type:Individual
Prefix:MRS
First Name:GERALYN
Middle Name:SUE
Last Name:PRULLAGE
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:GERALYN
Other - Middle Name:SUE
Other - Last Name:PRULLAGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APN
Mailing Address - Street 1:201 E MADISON ST STE 328
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-5131
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:
Practice Address - Street 1:415 N 9TH ST STE 4W16
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5303
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-15
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041207587363LN0005X
IL209008472363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care