Healthcare Provider Details

I. General information

NPI: 1871377713
Provider Name (Legal Business Name): LICETTE PRISCILLA CUAUTLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2023
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1508 ESSINGTON RD STE 5
JOLIET IL
60435-2875
US

IV. Provider business mailing address

1508 ESSINGTON RD STE 5
JOLIET IL
60435-2875
US

V. Phone/Fax

Practice location:
  • Phone: 815-733-5952
  • Fax: 888-550-5352
Mailing address:
  • Phone: 815-733-5952
  • Fax: 888-550-6381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.026373
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: