Provider Demographics
NPI:1982007878
Name:AGOSTINO, CHRISTINE
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:AGOSTINO
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 1:1340 S DAMEN AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1169
Mailing Address - Country:US
Mailing Address - Phone:773-292-4800
Mailing Address - Fax:773-384-7053
Practice Address - Street 1:1340 S DAMEN AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1169
Practice Address - Country:US
Practice Address - Phone:773-292-4800
Practice Address - Fax:773-384-7053
Is Sole Proprietor?:No
Enumeration Date:2014-10-06
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DELP-0000110363L00000X
TNLP-0000110363LG0600X
PASP017422363L00000X
TNL1-0029955163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse