Provider Demographics
NPI:1720578180
Name:DAGOSTIN, MARLENA
Entity type:Individual
Prefix:MRS
First Name:MARLENA
Middle Name:
Last Name:DAGOSTIN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 PRAIRIE ROSE DR
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-7792
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5000 PRAIRIE ROSE DR
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-7792
Practice Address - Country:US
Practice Address - Phone:815-971-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-11
Last Update Date:2025-02-28
Deactivation Date:2025-01-28
Deactivation Code:
Reactivation Date:2025-02-26
Provider Licenses
StateLicense IDTaxonomies
ILRBT-17-45125106S00000X
IL209.031411363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician