Provider Demographics
NPI:1356022578
Name:PRUSAKIEWICZ, BECKY (RN, FNP)
Entity type:Individual
Prefix:
First Name:BECKY
Middle Name:
Last Name:PRUSAKIEWICZ
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6052 W 817 N
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46349-9519
Mailing Address - Country:US
Mailing Address - Phone:567-825-8714
Mailing Address - Fax:
Practice Address - Street 1:200 E FAIRMAN AVE
Practice Address - Street 2:
Practice Address - City:WATSEKA
Practice Address - State:IL
Practice Address - Zip Code:60970-1644
Practice Address - Country:US
Practice Address - Phone:815-432-7722
Practice Address - Fax:815-432-7874
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28262434A163W00000X
IL209.028752363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse