Provider Demographics
NPI:1790381168
Name:PRYBYLOWSKI, CHARLES (APRN)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:PRYBYLOWSKI
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5775 INVERNESS DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-3819
Mailing Address - Country:US
Mailing Address - Phone:815-519-1393
Mailing Address - Fax:
Practice Address - Street 1:6700 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2199
Practice Address - Country:US
Practice Address - Phone:708-974-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209021228363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner