Healthcare Provider Details

I. General information

NPI: 1932756194
Provider Name (Legal Business Name): CARISSA COLE CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2019
Last Update Date: 05/01/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E SOUTHLINE RD
TUSCOLA IL
61953-2014
US

IV. Provider business mailing address

611 W. PARK ST. FAPC
URBANA IL
61801
US

V. Phone/Fax

Practice location:
  • Phone: 217-253-5231
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209019303
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209019303
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: