Healthcare Provider Details

I. General information

NPI: 1780370668
Provider Name (Legal Business Name): LAURETTA JOSANE KARGBO FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2023
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 75TH ST
WILLOWBROOK IL
60527-2325
US

IV. Provider business mailing address

7951 W 112TH PL
PALOS HILLS IL
60465-2728
US

V. Phone/Fax

Practice location:
  • Phone: 630-581-5372
  • Fax:
Mailing address:
  • Phone: 708-655-4860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.027095
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: