Healthcare Provider Details

I. General information

NPI: 1386565463
Provider Name (Legal Business Name): AVA GBRIELLA CAPOGRECO LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11531 SUNDERLAND RD
MARION IL
62959-8274
US

IV. Provider business mailing address

11693 SOUTHPOINT LN
WEST FRANKFORT IL
62896-4905
US

V. Phone/Fax

Practice location:
  • Phone: 618-964-5139
  • Fax:
Mailing address:
  • Phone: 618-889-1321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number043616138
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: