Healthcare Provider Details

I. General information

NPI: 1770617359
Provider Name (Legal Business Name): CAROL MRAVINAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 12/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11200 LINCOLN HWY
MOKENA IL
60448-8208
US

IV. Provider business mailing address

11200 LINCOLN HWY
MOKENA IL
60448-8208
US

V. Phone/Fax

Practice location:
  • Phone: 815-464-2171
  • Fax:
Mailing address:
  • Phone: 815-464-2171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number041330732
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: