Provider Demographics
NPI:1982314043
Name:IMMORDINO, CARLI (NURSE)
Entity type:Individual
Prefix:
First Name:CARLI
Middle Name:
Last Name:IMMORDINO
Suffix:
Gender:F
Credentials:NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 N OAKLEY BLVD APT 102
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-1225
Mailing Address - Country:US
Mailing Address - Phone:708-267-1708
Mailing Address - Fax:
Practice Address - Street 1:5201 WILLOW SPRINGS RD STE 440
Practice Address - Street 2:
Practice Address - City:LA GRANGE HIGHLANDS
Practice Address - State:IL
Practice Address - Zip Code:60525-6546
Practice Address - Country:US
Practice Address - Phone:708-482-3213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-30
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209026471363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner