Provider Demographics
NPI:1720326085
Name:WELLS, CAROLYN (RN)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:WELLS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 N LAKE SHORE DR
Mailing Address - Street 2:SUITE 818
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4546
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:75 REMITTANCE DR
Practice Address - Street 2:SUITE 1293
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60675-1293
Practice Address - Country:US
Practice Address - Phone:312-926-4392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-22
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041235044163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041235044OtherLICENSE