Provider Demographics
NPI:1700499274
Name:KALLAL, CARRIE H (MSN APRN)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:H
Last Name:KALLAL
Suffix:
Gender:F
Credentials:MSN APRN
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:H
Other - Last Name:PURDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5017 STATEN DR
Mailing Address - Street 2:
Mailing Address - City:GODFREY
Mailing Address - State:IL
Mailing Address - Zip Code:62035-1522
Mailing Address - Country:US
Mailing Address - Phone:618-946-7674
Mailing Address - Fax:618-498-8439
Practice Address - Street 1:390 MAPLE SUMMIT RD
Practice Address - Street 2:ILLINI BLDG
Practice Address - City:JERSEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62052
Practice Address - Country:US
Practice Address - Phone:618-498-2101
Practice Address - Fax:618-498-8153
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209021821363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics