Healthcare Provider Details

I. General information

NPI: 1548151475
Provider Name (Legal Business Name): CARLOS MALDONADO GARCIA APRN, CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 KISH HOSPITAL DR
DEKALB IL
60115-9602
US

IV. Provider business mailing address

1 KISH HOSPITAL DR
DEKALB IL
60115-9602
US

V. Phone/Fax

Practice location:
  • Phone: 815-766-7334
  • Fax: 815-766-9768
Mailing address:
  • Phone: 815-766-7334
  • Fax: 815-766-9768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209033922
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1703833
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: