Provider Demographics
NPI:1205983996
Name:INGRISANO, CAROL M (NP)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:M
Last Name:INGRISANO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15300 WEST AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-4600
Mailing Address - Country:US
Mailing Address - Phone:708-403-8400
Mailing Address - Fax:708-403-8492
Practice Address - Street 1:15300 WEST AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-4600
Practice Address - Country:US
Practice Address - Phone:708-403-8400
Practice Address - Fax:708-403-8492
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL202168Medicare ID - Type UnspecifiedMEDICARE PROVIDER NO.
ILP62491Medicare UPIN