Healthcare Provider Details

I. General information

NPI: 1033818612
Provider Name (Legal Business Name): AMELIA EILENE MERCER RN, AGPCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2023
Last Update Date: 10/05/2023
Certification Date: 10/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 W HARRISON ST
CHICAGO IL
60607-3106
US

IV. Provider business mailing address

1725 W HARRISON ST STE 809
CHICAGO IL
60612-3861
US

V. Phone/Fax

Practice location:
  • Phone: 832-492-7554
  • Fax:
Mailing address:
  • Phone: 312-942-5904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.027294
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: