Provider Demographics
NPI:1194022368
Name:CUNNINGHAM, CARRIE M (FNP)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:M
Last Name:CUNNINGHAM
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 1:2200 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:IL
Mailing Address - Zip Code:61944-2966
Mailing Address - Country:US
Mailing Address - Phone:217-463-4340
Mailing Address - Fax:217-463-4342
Practice Address - Street 1:2200 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:IL
Practice Address - Zip Code:61944
Practice Address - Country:US
Practice Address - Phone:217-463-4340
Practice Address - Fax:217-463-4342
Is Sole Proprietor?:No
Enumeration Date:2011-02-23
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28179464A363LF0000X
IL209.017707363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000740975OtherANTHEM
IN201029170Medicaid
INM400059831Medicare PIN