Basic Information
| Provider Information | |||||||||
| NPI: | 1700499274 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PURDY | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSN APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KALLAL | ||||||||
| OtherFirstName: | CARRIE | ||||||||
| OtherMiddleName: | H | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5017 STATEN DR | ||||||||
| Address2: | |||||||||
| City: | GODFREY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620351522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189467674 | ||||||||
| FaxNumber: | 6184988439 | ||||||||
| Practice Location | |||||||||
| Address1: | 390 MAPLE SUMMIT RD | ||||||||
| Address2: | ILLINI BLDG | ||||||||
| City: | JERSEYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184982101 | ||||||||
| FaxNumber: | 6184988153 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2020 | ||||||||
| LastUpdateDate: | 08/25/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 209021821 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.