Healthcare Provider Details

I. General information

NPI: 1700313202
Provider Name (Legal Business Name): CARISSA WATERS APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2017
Last Update Date: 05/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 W WELLINGTON AVE
CHICAGO IL
60657-5147
US

IV. Provider business mailing address

541 W OAKDALE AVE APT 402
CHICAGO IL
60657-5736
US

V. Phone/Fax

Practice location:
  • Phone: 773-296-1295
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2100X
TaxonomyAcute Care Clinical Nurse Specialist
License Number209015912
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: