Basic Information
| Provider Information | |||||||||
| NPI: | 1851640825 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARMACK | ||||||||
| FirstName: | CHERYL | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NAFZIGER | ||||||||
| OtherFirstName: | CHERYL | ||||||||
| OtherMiddleName: | A | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1231 KLEEMANN DR | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617272633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2179355022 | ||||||||
| FaxNumber: | 2179359592 | ||||||||
| Practice Location | |||||||||
| Address1: | 1231 KLEEMANN DR | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617272633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2179355022 | ||||||||
| FaxNumber: | 2179359592 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2012 | ||||||||
| LastUpdateDate: | 10/25/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209-009693 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 209-009693 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.