Healthcare Provider Details

I. General information

NPI: 1609343128
Provider Name (Legal Business Name): KATY JO NORTHCUTT APRN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2018
Last Update Date: 10/23/2025
Certification Date: 10/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 HEARTLAND DR STE C
BLOOMINGTON IL
61704-7733
US

IV. Provider business mailing address

611 W PARK ST
URBANA IL
61801-2501
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-7642
  • Fax: 309-663-8359
Mailing address:
  • Phone: 217-383-3311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209018225
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: