Basic Information
| Provider Information | |||||||||
| NPI: | 1174838684 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZAKUSILOV | ||||||||
| FirstName: | SYLVIA | ||||||||
| MiddleName: | JOY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SWAN | ||||||||
| OtherFirstName: | SYLVIA | ||||||||
| OtherMiddleName: | JOY | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1241 | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466241241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8856919888 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 600 EAST BLVD | ||||||||
| Address2: | |||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465142483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745233160 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2010 | ||||||||
| LastUpdateDate: | 04/05/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 28164101A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 000000672495 | 01 | IN | ANTHEM | OTHER | 200994950 | 05 | IN | MEDICAID |