Healthcare Provider Details

I. General information

NPI: 1083242044
Provider Name (Legal Business Name): KORETTA G SYKES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 03/27/2020
Certification Date: 03/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1517 S 12TH ST
QUINCY IL
62301-6759
US

IV. Provider business mailing address

2525 ELM ST
QUINCY IL
62301-3535
US

V. Phone/Fax

Practice location:
  • Phone: 217-228-1974
  • Fax:
Mailing address:
  • Phone: 217-617-6964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number3336
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: