Provider Demographics
NPI:1265077184
Name:INOCENCIO, HAROLD (FNP-BC)
Entity type:Individual
Prefix:
First Name:HAROLD
Middle Name:
Last Name:INOCENCIO
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8644 BALLARD DR
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60487-3097
Mailing Address - Country:US
Mailing Address - Phone:773-517-6778
Mailing Address - Fax:
Practice Address - Street 1:8644 BALLARD DR
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60487-3097
Practice Address - Country:US
Practice Address - Phone:773-517-6778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-14
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.016737363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner