Provider Demographics
NPI:1891441515
Name:PHILLIPS, KATELYN SUE (DNP)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:SUE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:SUE
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:390 MAPLE SUMMIT RD
Mailing Address - Street 2:
Mailing Address - City:JERSEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62052-2000
Mailing Address - Country:US
Mailing Address - Phone:618-498-7518
Mailing Address - Fax:618-498-3052
Practice Address - Street 1:903 S STATE ST
Practice Address - Street 2:
Practice Address - City:JERSEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62052-2344
Practice Address - Country:US
Practice Address - Phone:618-639-9255
Practice Address - Fax:618-639-8100
Is Sole Proprietor?:No
Enumeration Date:2022-02-22
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209027803363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily