Provider Demographics
NPI:1558068171
Name:SULCER, KYLA GELINA (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KYLA
Middle Name:GELINA
Last Name:SULCER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1191 FORTUNE BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:SHILOH
Mailing Address - State:IL
Mailing Address - Zip Code:62269-7474
Mailing Address - Country:US
Mailing Address - Phone:618-607-0061
Mailing Address - Fax:618-615-4290
Practice Address - Street 1:1191 FORTUNE BLVD STE 2
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-7474
Practice Address - Country:US
Practice Address - Phone:618-607-0061
Practice Address - Fax:618-615-4290
Is Sole Proprietor?:No
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.007051225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant