Provider Demographics
NPI:1104822568
Name:CARR, PATRICIA E (FNP)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:E
Last Name:CARR
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 N EDWARD ST
Mailing Address - Street 2:GSBLL
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-4163
Mailing Address - Country:US
Mailing Address - Phone:217-876-2857
Mailing Address - Fax:217-876-2874
Practice Address - Street 1:1220 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:IL
Practice Address - Zip Code:61951-1032
Practice Address - Country:US
Practice Address - Phone:217-728-2042
Practice Address - Fax:217-728-2485
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209003187363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP64995Medicare UPIN