Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 209014711 | IL |
NPI | 1003361049 |
---|---|
Provider Name | Courtney Harley |
First Address | Sandwich, IL 60548-2016 |
Second Address | Aurora, IL 60502-9300 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/08/2016 |
Last Update Date | 19/08/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
209014711 | (05) | IL |