Provider Demographics
NPI:1205173903
Name:JANICH, CARMEN
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:JANICH
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 1:1316 KENT CT
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60189-8511
Mailing Address - Country:US
Mailing Address - Phone:630-784-0074
Mailing Address - Fax:
Practice Address - Street 1:143 S LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60505-4263
Practice Address - Country:US
Practice Address - Phone:630-897-0091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-15
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.320025163W00000X
IL209.010251364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041.320025Medicaid
IL041.320025Medicare PIN
IL041.320025Medicaid