Provider Demographics
NPI:1669741997
Name:RUGINO, KATELYN M (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KATELYN
Middle Name:M
Last Name:RUGINO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:KATELYN
Other - Middle Name:M
Other - Last Name:BEACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:375 N WALL ST STE 530
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-3483
Mailing Address - Country:US
Mailing Address - Phone:815-932-7200
Mailing Address - Fax:815-935-8797
Practice Address - Street 1:375 N WALL ST STE 530
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-3483
Practice Address - Country:US
Practice Address - Phone:815-932-7200
Practice Address - Fax:815-935-8797
Is Sole Proprietor?:No
Enumeration Date:2011-12-15
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004856RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant