Provider Demographics
NPI:1215623178
Name:CAPA, RICHARD ERICKSON (LPN)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:ERICKSON
Last Name:CAPA
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18608 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GAGES LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-1755
Mailing Address - Country:US
Mailing Address - Phone:847-912-3715
Mailing Address - Fax:
Practice Address - Street 1:8207 22ND AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-6206
Practice Address - Country:US
Practice Address - Phone:262-653-9286
Practice Address - Fax:224-610-2601
Is Sole Proprietor?:No
Enumeration Date:2023-04-13
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.117020164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse