Provider Demographics
NPI:1619444239
Name:SANSONE, KAYLIN RENAE
Entity Type:Individual
Prefix:
First Name:KAYLIN
Middle Name:RENAE
Last Name:SANSONE
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 1:6205 NELDER DR
Mailing Address - Street 2:
Mailing Address - City:GODFREY
Mailing Address - State:IL
Mailing Address - Zip Code:62035-2449
Mailing Address - Country:US
Mailing Address - Phone:618-420-6677
Mailing Address - Fax:
Practice Address - Street 1:6205 NELDER DR
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-2449
Practice Address - Country:US
Practice Address - Phone:618-420-6677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-01
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057004473224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant