Provider Demographics
NPI:1922021286
Name:BOLEK, CARLA (APRN)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:BOLEK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 LEE ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-4539
Mailing Address - Country:US
Mailing Address - Phone:847-390-5900
Mailing Address - Fax:
Practice Address - Street 1:415 W FRONT ST
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:IL
Practice Address - Zip Code:61561-7817
Practice Address - Country:US
Practice Address - Phone:309-923-7456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209004989363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL01X2OtherJOHN DEERE
IL7215059OtherBCBS PPO
IL472312OtherHEALTHLINK
ILP00293738OtherRAILROAD MEDICARE
ILK24592Medicare ID - Type Unspecified
ILQ45893Medicare UPIN