Provider Demographics
NPI:1003361049
Name:HARLEY, COURTNEY (ANP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:HARLEY
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 DAVIS ST
Mailing Address - Street 2:
Mailing Address - City:SANDWICH
Mailing Address - State:IL
Mailing Address - Zip Code:60548-2016
Mailing Address - Country:US
Mailing Address - Phone:815-526-2497
Mailing Address - Fax:
Practice Address - Street 1:2720 E NEW YORK ST
Practice Address - Street 2:STE 108
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60502-9300
Practice Address - Country:US
Practice Address - Phone:630-820-7045
Practice Address - Fax:630-820-7047
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-19
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209014711363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209014711Medicaid