Provider Demographics
NPI:1033515036
Name:ANDERSON, CARRIE L
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:L
Last Name:ANDERSON
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 1:1725 W HARRISON ST STE 207
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3988
Mailing Address - Country:US
Mailing Address - Phone:312-942-5861
Mailing Address - Fax:312-942-7394
Practice Address - Street 1:1725 W HARRISON ST STE 207
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3988
Practice Address - Country:US
Practice Address - Phone:312-942-5861
Practice Address - Fax:312-942-7394
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-18
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209012068363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0000000OtherMEDICARE ID -TYPE UNSPECIFIED
IL0000000Medicaid