Provider Demographics
NPI:1033871744
Name:LUPTON, KATIE LARISSA
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:LARISSA
Last Name:LUPTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:LARISSA
Other - Last Name:CONBOY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1249 OMEGA CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-5809
Mailing Address - Country:US
Mailing Address - Phone:815-501-3121
Mailing Address - Fax:
Practice Address - Street 1:1249 OMEGA CIRCLE DR
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-5809
Practice Address - Country:US
Practice Address - Phone:815-501-3121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-10
Last Update Date:2021-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043106608164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse