Healthcare Provider Details

I. General information

NPI: 1245500610
Provider Name (Legal Business Name): MARY WELTI ANP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2012
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12504 SE 93RD COURT RD
SUMMERFIELD FL
34491-9722
US

IV. Provider business mailing address

12504 SE 93RD COURT RD
SUMMERFIELD FL
34491-9722
US

V. Phone/Fax

Practice location:
  • Phone: 312-371-4513
  • Fax:
Mailing address:
  • Phone: 312-371-4513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209.009155
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: