Provider Demographics
NPI:1336830918
Name:UTLEY, JUSTIN ERIK
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ERIK
Last Name:UTLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 HARLEM RD
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-2754
Mailing Address - Country:US
Mailing Address - Phone:815-877-4848
Mailing Address - Fax:815-636-6125
Practice Address - Street 1:2202 HARLEM RD
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-2754
Practice Address - Country:US
Practice Address - Phone:815-877-4848
Practice Address - Fax:815-636-6125
Is Sole Proprietor?:No
Enumeration Date:2023-05-16
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209028630367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered