Provider Demographics
NPI:1356935100
Name:KOSYDOR, JAYDA LEA (APRN)
Entity type:Individual
Prefix:
First Name:JAYDA
Middle Name:LEA
Last Name:KOSYDOR
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JAYDA
Other - Middle Name:LEA
Other - Last Name:KOSYDOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN
Mailing Address - Street 1:3412 OFFICE PARK DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-6477
Mailing Address - Country:US
Mailing Address - Phone:618-993-0404
Mailing Address - Fax:
Practice Address - Street 1:3412 OFFICE PARK DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-6477
Practice Address - Country:US
Practice Address - Phone:618-993-0404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-23
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209022897363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics