Provider Demographics
NPI:1356069207
Name:MOSEBERRY, CARLY BRITT (APN-CNP)
Entity type:Individual
Prefix:MS
First Name:CARLY
Middle Name:BRITT
Last Name:MOSEBERRY
Suffix:
Gender:F
Credentials:APN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 RIDGE AVE. SUITE 1223
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1718
Mailing Address - Country:US
Mailing Address - Phone:847-570-2040
Mailing Address - Fax:
Practice Address - Street 1:2050 PFINGSTEN RD. SUITE 330
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-1300
Practice Address - Country:US
Practice Address - Phone:847-570-2868
Practice Address - Fax:847-733-5005
Is Sole Proprietor?:No
Enumeration Date:2022-08-17
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209025304363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209025304OtherIL LICENSE