Healthcare Provider Details

I. General information

NPI: 1528549474
Provider Name (Legal Business Name): CAROLINE HAUGHEY DUBORD APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2018
Last Update Date: 12/28/2019
Certification Date: 12/28/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 N SAINT CLAIR ST STE 19-250
CHICAGO IL
60611-5964
US

IV. Provider business mailing address

675 N SAINT CLAIR ST STE 19-250
CHICAGO IL
60611-5964
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-6022
  • Fax: 312-695-5672
Mailing address:
  • Phone: 312-695-6022
  • Fax: 312-695-5672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041429204
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WS0121X
TaxonomyPlastic Surgery Registered Nurse
License Number041429204
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209.018088
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.018088
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: