Provider Demographics
NPI:1326791914
Name:WIERSUM, VIOLET CORINNE BOOTHE (APRN, CNP)
Entity Type:Individual
Prefix:
First Name:VIOLET
Middle Name:CORINNE BOOTHE
Last Name:WIERSUM
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:VIOLET
Other - Middle Name:
Other - Last Name:BOOTHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:676 N SAINT CLAIR ST STE 14-044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2927
Mailing Address - Country:US
Mailing Address - Phone:312-908-8163
Mailing Address - Fax:312-695-1394
Practice Address - Street 1:676 N SAINT CLAIR ST STE 14-044
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2927
Practice Address - Country:US
Practice Address - Phone:312-908-8163
Practice Address - Fax:312-695-1394
Is Sole Proprietor?:No
Enumeration Date:2022-02-02
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041421701163WC0200X
IL209025108363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care