Provider Demographics
NPI:1659656486
Name:CARCELLAR, MARIE R (CNP)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:R
Last Name:CARCELLAR
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:R
Other - Last Name:DELEON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5101 S WILLOW SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-7009
Mailing Address - Country:US
Mailing Address - Phone:708-245-4073
Mailing Address - Fax:708-245-5614
Practice Address - Street 1:5101 S WILLOW SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-7009
Practice Address - Country:US
Practice Address - Phone:708-245-4073
Practice Address - Fax:708-245-5614
Is Sole Proprietor?:No
Enumeration Date:2011-10-12
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209008874363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
208341OtherGROUP PTAN
208342OtherMEDICARE GROUP PTAN