Provider Demographics
NPI:1629375985
Name:SEBASTIAN, GRACYKUTTY T (CNP)
Entity Type:Individual
Prefix:
First Name:GRACYKUTTY
Middle Name:T
Last Name:SEBASTIAN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 W MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-8409
Mailing Address - Country:US
Mailing Address - Phone:815-759-4323
Mailing Address - Fax:815-759-4948
Practice Address - Street 1:4201 W MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-8409
Practice Address - Country:US
Practice Address - Phone:815-759-4323
Practice Address - Fax:815-759-4948
Is Sole Proprietor?:No
Enumeration Date:2011-02-23
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-007338363L00000X
IL209007338364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209007338OtherSTATE LICENSE