Healthcare Provider Details

I. General information

NPI: 1720578180
Provider Name (Legal Business Name): MRS. MARLENA DAGOSTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2018
Last Update Date: 02/28/2025
Certification Date: 02/28/2025
Deactivation Date: 01/28/2025
Reactivation Date: 02/26/2025

III. Provider practice location address

5000 PRAIRIE ROSE DR
ROSCOE IL
61073-7792
US

IV. Provider business mailing address

5000 PRAIRIE ROSE DR
ROSCOE IL
61073-7792
US

V. Phone/Fax

Practice location:
  • Phone: 815-971-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-17-45125
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.031411
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: