Healthcare Provider Details

I. General information

NPI: 1023776622
Provider Name (Legal Business Name): MARY LOUISE MCWETHY NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2021
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 HAHNS PEAK DR
LOVELAND CO
80538-8852
US

IV. Provider business mailing address

1115 WHITE ROCK DR
DIXON IL
61021-9050
US

V. Phone/Fax

Practice location:
  • Phone: 307-920-2997
  • Fax:
Mailing address:
  • Phone: 815-440-7901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPN.0999064-NP
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209023913
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN.0999064-NP
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.406026
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: