Healthcare Provider Details

I. General information

NPI: 1881133114
Provider Name (Legal Business Name): MARY LAIRD NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2017
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W UNIVERSITY AVE
CHAMPAIGN IL
61820-3981
US

IV. Provider business mailing address

101 W UNIVERSITY AVE
CHAMPAIGN IL
61820-3981
US

V. Phone/Fax

Practice location:
  • Phone: 217-366-1255
  • Fax: 217-352-9658
Mailing address:
  • Phone: 217-366-1255
  • Fax: 217-352-9658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number277003714
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71006877A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: