Healthcare Provider Details

I. General information

NPI: 1548644545
Provider Name (Legal Business Name): KATELYN MARIE VANDERMAST APN, FNP-BC, NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2015
Last Update Date: 07/28/2023
Certification Date: 09/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 GATEWAY DR STE 201
SYCAMORE IL
60178-3192
US

IV. Provider business mailing address

1850 GATEWAY DR STE 201
SYCAMORE IL
60178-3192
US

V. Phone/Fax

Practice location:
  • Phone: 815-766-7021
  • Fax: 815-758-5690
Mailing address:
  • Phone: 815-766-7021
  • Fax: 815-758-5690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209013007
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number209013007
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number209013007
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041-390433
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: