Provider Demographics
NPI:1013161173
Name:CARLSON, NICOLE W (RN, CPNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:W
Last Name:CARLSON
Suffix:
Gender:F
Credentials:RN, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5839 S MARYLAND AVE
Mailing Address - Street 2:MC 5044
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-1463
Mailing Address - Country:US
Mailing Address - Phone:773-702-2186
Mailing Address - Fax:
Practice Address - Street 1:5839 S MARYLAND AVE
Practice Address - Street 2:MC 5044
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1463
Practice Address - Country:US
Practice Address - Phone:773-702-2186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-14
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209004914363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics