Healthcare Provider Details

I. General information

NPI: 1194792325
Provider Name (Legal Business Name): MARY JANE TOLES APN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 S DAMEN AVE
CHICAGO IL
60612-3728
US

IV. Provider business mailing address

12014 S PERRY AVE
CHICAGO IL
60628-6625
US

V. Phone/Fax

Practice location:
  • Phone: 312-569-6354
  • Fax: 312-569-6112
Mailing address:
  • Phone: 773-928-1213
  • Fax: 312-569-6112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: