Provider Demographics
NPI:1982688263
Name:LADISLAS, GAYNELL SUE (APN)
Entity Type:Individual
Prefix:MRS
First Name:GAYNELL
Middle Name:SUE
Last Name:LADISLAS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:MRS
Other - First Name:GAYNELL
Other - Middle Name:SUE
Other - Last Name:LADISLAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:104 N GARFIELD ST
Mailing Address - Street 2:
Mailing Address - City:OBLONG
Mailing Address - State:IL
Mailing Address - Zip Code:62449-1426
Mailing Address - Country:US
Mailing Address - Phone:618-592-3119
Mailing Address - Fax:618-592-3875
Practice Address - Street 1:104 N GARFIELD ST
Practice Address - Street 2:
Practice Address - City:OBLONG
Practice Address - State:IL
Practice Address - Zip Code:62449-1426
Practice Address - Country:US
Practice Address - Phone:618-592-3119
Practice Address - Fax:618-592-3875
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209003339363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
R16747Medicare UPIN
ILL99757Medicare ID - Type Unspecified