Provider Demographics
NPI:1871377713
Name:CUAUTLE, LICETTE PRISCILLA
Entity type:Individual
Prefix:
First Name:LICETTE
Middle Name:PRISCILLA
Last Name:CUAUTLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 ESSINGTON RD STE 5
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-2875
Mailing Address - Country:US
Mailing Address - Phone:815-733-5952
Mailing Address - Fax:888-550-6381
Practice Address - Street 1:1508 ESSINGTON RD STE 5
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-2875
Practice Address - Country:US
Practice Address - Phone:815-733-5952
Practice Address - Fax:888-550-5352
Is Sole Proprietor?:No
Enumeration Date:2023-08-22
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.026373363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily