Provider Demographics
NPI:1255689543
Name:DAGDICK, LAURA L (CNP)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:L
Last Name:DAGDICK
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:L
Other - Last Name:GRAVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:650 DAKOTA ST STE A
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60012-3744
Mailing Address - Country:US
Mailing Address - Phone:815-338-6600
Mailing Address - Fax:815-356-1104
Practice Address - Street 1:650 DAKOTA ST STE A
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60012-3744
Practice Address - Country:US
Practice Address - Phone:815-455-6000
Practice Address - Fax:815-356-1104
Is Sole Proprietor?:No
Enumeration Date:2012-08-17
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009741363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209009741OtherSTATE LICENSE