Provider Demographics
NPI:1750823183
Name:BLUNDY, KAYLA (NP)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:BLUNDY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2529
Mailing Address - Country:US
Mailing Address - Phone:217-383-6941
Mailing Address - Fax:
Practice Address - Street 1:801 E ORANGE ST
Practice Address - Street 2:FAMILY MED
Practice Address - City:HOOPESTON
Practice Address - State:IL
Practice Address - Zip Code:60942-1802
Practice Address - Country:US
Practice Address - Phone:217-283-5644
Practice Address - Fax:217-283-7981
Is Sole Proprietor?:No
Enumeration Date:2016-11-16
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041355856163W00000X
IL209015599363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse