Provider Demographics
NPI:1932505302
Name:COYLE, SALLY N (APN)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:N
Last Name:COYLE
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 NE RANDOLPH AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606-1919
Mailing Address - Country:US
Mailing Address - Phone:309-624-8500
Mailing Address - Fax:309-624-8552
Practice Address - Street 1:100 NE RANDOLPH AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-1919
Practice Address - Country:US
Practice Address - Phone:309-624-8500
Practice Address - Fax:309-624-8552
Is Sole Proprietor?:No
Enumeration Date:2014-11-13
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.012192363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner