Provider Demographics
NPI:1841988573
Name:UNDERKOFFLER, CARLY ANN (FNP-C)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:ANN
Last Name:UNDERKOFFLER
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 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1293
Mailing Address - Country:US
Mailing Address - Phone:847-390-5900
Mailing Address - Fax:
Practice Address - Street 1:3134 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-4414
Practice Address - Country:US
Practice Address - Phone:312-766-4917
Practice Address - Fax:773-880-9723
Is Sole Proprietor?:No
Enumeration Date:2023-05-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209026650363LF0000X
IL041453660163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse