Provider Demographics
NPI:1285402099
Name:CARLSON, MCKENNA (APN)
Entity type:Individual
Prefix:
First Name:MCKENNA
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 713260
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:1300 ARLINGTON HEIGHTS RD
Practice Address - Street 2:STE 130
Practice Address - City:ITASCA
Practice Address - State:IL
Practice Address - Zip Code:60143
Practice Address - Country:US
Practice Address - Phone:847-871-4540
Practice Address - Fax:847-871-4597
Is Sole Proprietor?:No
Enumeration Date:2023-12-12
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209028730363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner