MEDICARE: MRS. CAROL FOGARTY CRNFA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	0411688853	IL

General Provider Information

NPI Number	:	1770891384
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CAROL FOGARTY CRNFA

Provider Business Mailing Address
First Line	:	11757 SOUTHWEST HWY
Second Line	:
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-1015
Country	:	US
Telephone Number	:	708-361-3930
Fax Number	:	708-361-7969

Provider Business Practice Location Address
First Line	:	11757 SOUTHWEST HWY
Second Line	:
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-1015
Country	:	US
Telephone Number	:	708-361-3930
Fax Number	:	708-361-7969

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2010
Last Update Date	:	09/16/2010

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