Provider Demographics
NPI:1912093816
Name:GRAVLIN, CARA A (ACNP)
Entity Type:Individual
Prefix:
First Name:CARA
Middle Name:A
Last Name:GRAVLIN
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:CARA
Other - Middle Name:A
Other - Last Name:CROWE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:102 W KENWOOD AVE LOWR LEVEL
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-4368
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-4485
Practice Address - Street 1:102 W KENWOOD AVE LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4368
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-4485
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-005882363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid