Healthcare Provider Details

I. General information

NPI: 1740017938
Provider Name (Legal Business Name): CAITLYN NICOLE EASLEY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2024
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 NE GLEN OAK AVE
PEORIA IL
61637-0001
US

IV. Provider business mailing address

601 W MELBOURNE AVE
PEORIA IL
61604-2845
US

V. Phone/Fax

Practice location:
  • Phone: 309-624-0629
  • Fax:
Mailing address:
  • Phone: 309-657-6820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number209030522
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number209.030522
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: