MEDICARE: MARY ODEFADEHAN FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	209021315	IL

General Provider Information

NPI Number	:	1881212157
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY ODEFADEHAN FNP-C

Provider Business Mailing Address
First Line	:	1005 S EVERGREEN AVE
Second Line	:
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60005-3144
Country	:	US
Telephone Number	:	847-787-3734
Fax Number	:

Provider Business Practice Location Address
First Line	:	1005 S EVERGREEN AVE
Second Line	:
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60005-3144
Country	:	US
Telephone Number	:	847-787-3734
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2020
Last Update Date	:	07/13/2020

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