Healthcare Provider Details

I. General information

NPI: 1164960001
Provider Name (Legal Business Name): ABIGAIL CONLON WHITE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2017
Last Update Date: 07/26/2023
Certification Date: 07/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE
EVANSTON IL
60201-1700
US

IV. Provider business mailing address

680 N LAKE SHORE DRIVE
CHICAGO IL
60611-2987
US

V. Phone/Fax

Practice location:
  • Phone: 847-982-3188
  • Fax:
Mailing address:
  • Phone: 312-695-6868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number228273
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041448624
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209016104
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: