Healthcare Provider Details

I. General information

NPI: 1962516773
Provider Name (Legal Business Name): CAROLYN A. DICKENS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 02/24/2025
Certification Date: 02/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W TAYLOR ST
CHICAGO IL
60612-7232
US

IV. Provider business mailing address

809 S MARSHFIELD AVE 9TH FLOOR (M/C 732)
CHICAGO IL
60612-4305
US

V. Phone/Fax

Practice location:
  • Phone: 866-600-2273
  • Fax:
Mailing address:
  • Phone: 312-996-7699
  • Fax: 312-996-1001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number041312669
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number277.002899
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number277.002899
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: