Provider Demographics
NPI:1699502732
Name:BLANCO PULIDO, KRISLEEN A (APRN)
Entity type:Individual
Prefix:
First Name:KRISLEEN
Middle Name:A
Last Name:BLANCO PULIDO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 E ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-4647
Mailing Address - Country:US
Mailing Address - Phone:224-365-8112
Mailing Address - Fax:
Practice Address - Street 1:244 E ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-4647
Practice Address - Country:US
Practice Address - Phone:224-365-8112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-13
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.030444363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner