Provider Demographics
NPI:1306410816
Name:ANDERSON, CAROLYN JEAN
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:JEAN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:644 S YORK RD APT 112
Mailing Address - Street 2:
Mailing Address - City:BENSENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60106-3048
Mailing Address - Country:US
Mailing Address - Phone:773-870-7599
Mailing Address - Fax:
Practice Address - Street 1:644 S YORK RD APT 112
Practice Address - Street 2:
Practice Address - City:BENSENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60106-3048
Practice Address - Country:US
Practice Address - Phone:773-870-7599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS166820376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide