Provider Demographics
NPI:1194942029
Name:WARDLAW, CAROL PALMER (RN,APN)
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:PALMER
Last Name:WARDLAW
Suffix:
Gender:F
Credentials:RN,APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13000 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-2318
Mailing Address - Country:US
Mailing Address - Phone:708-385-6100
Mailing Address - Fax:708-385-2051
Practice Address - Street 1:13000 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-2318
Practice Address - Country:US
Practice Address - Phone:708-385-6100
Practice Address - Fax:708-385-2051
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209002606163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK46565Medicare PIN
367830Medicare PIN
ILK46564Medicare PIN