Healthcare Provider Details

I. General information

NPI: 1649998139
Provider Name (Legal Business Name): CARLYN NEWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2022
Last Update Date: 11/03/2022
Certification Date: 11/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 W 203RD ST STE 202
OLYMPIA FIELDS IL
60461-1185
US

IV. Provider business mailing address

35318 EAGLE WAY
CHICAGO IL
60678-1353
US

V. Phone/Fax

Practice location:
  • Phone: 708-852-2699
  • Fax: 708-679-2223
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number209025274
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License Number041388238
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License Number209025274
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: