Provider Demographics
NPI:1326473950
Name:CARLSON, BREANNA JEAN
Entity Type:Individual
Prefix:MS
First Name:BREANNA
Middle Name:JEAN
Last Name:CARLSON
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 1:6301 N SHERIDAN RD
Mailing Address - Street 2:APT 4V
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-1728
Mailing Address - Country:US
Mailing Address - Phone:218-348-4595
Mailing Address - Fax:
Practice Address - Street 1:7000 N MCCORMICK BLVD
Practice Address - Street 2:
Practice Address - City:LINCOLNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60712-2726
Practice Address - Country:US
Practice Address - Phone:888-325-0862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-13
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility