Healthcare Provider Details

I. General information

NPI: 1003061896
Provider Name (Legal Business Name): MARILYN KAY SPALLA M.ED.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2008
Last Update Date: 11/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5259 S NORDICA AVE
CHICAGO IL
60638-1015
US

IV. Provider business mailing address

5259 S NORDICA AVE
CHICAGO IL
60638-1015
US

V. Phone/Fax

Practice location:
  • Phone: 773-339-3876
  • Fax:
Mailing address:
  • Phone: 773-339-3876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number2244762 ; 2359916
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: