Basic Information
| Provider Information | |||||||||
| NPI: | 1467858308 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUZLAS | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | MAE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 W UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618203981 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173666162 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3101 FIELDS SOUTH DR | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618223743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173666162 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2014 | ||||||||
| LastUpdateDate: | 01/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209.012016 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.