Provider Demographics
NPI:1750971792
Name:GRAHOVAC, CASSONDRA (FNP-C)
Entity type:Individual
Prefix:
First Name:CASSONDRA
Middle Name:
Last Name:GRAHOVAC
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4121 FAIRVIEW AVE STE L2
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-2275
Mailing Address - Country:US
Mailing Address - Phone:630-968-1700
Mailing Address - Fax:
Practice Address - Street 1:8840 CALUMET AVE STE 206
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2546
Practice Address - Country:US
Practice Address - Phone:219-836-7723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-23
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.022623363LF0000X
IN71010908A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty