Healthcare Provider Details

I. General information

NPI: 1013365360
Provider Name (Legal Business Name): LARRY JAMES MATURIN JR. RN, APN, ACNS-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2016
Last Update Date: 05/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

990 W FULLERTON AVE
CHICAGO IL
60614-2458
US

IV. Provider business mailing address

3704 HARMS RD
JOLIET IL
60435-9046
US

V. Phone/Fax

Practice location:
  • Phone: 815-603-6212
  • Fax:
Mailing address:
  • Phone: 815-603-6212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number041.323524
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number209.010006
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number209.010006
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: