Provider Demographics
NPI:1366795049
Name:DEBRUHL, CAROL A (APN, FNP)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:DEBRUHL
Suffix:
Gender:F
Credentials:APN, FNP
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:
Other - Last Name:UNDERWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:530 PARK AVE E
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356-3901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:535 PARK AVE E
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356-2537
Practice Address - Country:US
Practice Address - Phone:815-875-4531
Practice Address - Fax:815-876-2119
Is Sole Proprietor?:No
Enumeration Date:2012-10-18
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209002921363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209002921Medicaid