Provider Demographics
NPI:1174838684
Name:ZAKUSILOV, SYLVIA JOY (NP)
Entity type:Individual
Prefix:
First Name:SYLVIA
Middle Name:JOY
Last Name:ZAKUSILOV
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SYLVIA
Other - Middle Name:JOY
Other - Last Name:SWAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1241
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46624-1241
Mailing Address - Country:US
Mailing Address - Phone:885-691-9888
Mailing Address - Fax:
Practice Address - Street 1:600 EAST BLVD
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2483
Practice Address - Country:US
Practice Address - Phone:574-523-3160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-10
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28164101A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000672495OtherANTHEM
IN200994950Medicaid
INM400021899Medicare PIN