Basic Information
| Provider Information | |||||||||
| NPI: | 1326791914 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIERSUM | ||||||||
| FirstName: | VIOLET | ||||||||
| MiddleName: | CORINNE BOOTHE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN, CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOOTHE | ||||||||
| OtherFirstName: | VIOLET | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 676 N SAINT CLAIR ST STE 14-044 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129088163 | ||||||||
| FaxNumber: | 3126951394 | ||||||||
| Practice Location | |||||||||
| Address1: | 676 N SAINT CLAIR ST STE 14-044 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129088163 | ||||||||
| FaxNumber: | 3126951394 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2022 | ||||||||
| LastUpdateDate: | 09/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC0200X | 041421701 | IL | N | Nursing Service Providers | Registered Nurse | Critical Care Medicine | 363LA2100X | 209025108 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363L00000X | 209025108 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.