Provider Demographics
NPI:1992705784
Name:NELSON, CARRIE N (DPM)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:N
Last Name:NELSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5670
Mailing Address - Street 2:
Mailing Address - City:VILLA PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60181-5670
Mailing Address - Country:US
Mailing Address - Phone:847-705-6765
Mailing Address - Fax:630-359-4600
Practice Address - Street 1:1320 CHASE ST STE 1A
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-9668
Practice Address - Country:US
Practice Address - Phone:847-705-6765
Practice Address - Fax:630-359-4600
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004921213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004921Medicaid