Healthcare Provider Details

I. General information

NPI: 1386556272
Provider Name (Legal Business Name): MARY DODDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARCI DODDS RN

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 N LAKE SHORE DR APT 11C
CHICAGO IL
60657-1927
US

IV. Provider business mailing address

3500 N LAKE SHORE DR APT 11C
CHICAGO IL
60657-1927
US

V. Phone/Fax

Practice location:
  • Phone: 217-377-6171
  • Fax:
Mailing address:
  • Phone: 217-377-6171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number041409034
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number041409034
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: