Provider Demographics
NPI:1588257133
Name:DECARLO, LIDUVINA ISABEL (APRN)
Entity type:Individual
Prefix:
First Name:LIDUVINA
Middle Name:ISABEL
Last Name:DECARLO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:LIDUVINA
Other - Middle Name:ISABEL
Other - Last Name:PORTILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:7926 PRESTON HWY STE 103
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-3848
Practice Address - Country:US
Practice Address - Phone:502-861-4652
Practice Address - Fax:502-272-5116
Is Sole Proprietor?:No
Enumeration Date:2021-02-15
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3015158363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner