Healthcare Provider Details

I. General information

NPI: 1396387247
Provider Name (Legal Business Name): STACEY LYNN ROKUSEK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2019
Last Update Date: 03/19/2020
Certification Date: 03/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 ESSINGTON RD
JOLIET IL
60435-8439
US

IV. Provider business mailing address

951 ESSINGTON RD
JOLIET IL
60435-8439
US

V. Phone/Fax

Practice location:
  • Phone: 815-744-4551
  • Fax: 815-744-4756
Mailing address:
  • Phone: 815-744-4551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209019709
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: