Healthcare Provider Details

I. General information

NPI: 1265373310
Provider Name (Legal Business Name): MARY SPEDALE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 W NELSON ST
CHICAGO IL
60657-6704
US

IV. Provider business mailing address

900 W NELSON ST
CHICAGO IL
60657-6704
US

V. Phone/Fax

Practice location:
  • Phone: 773-296-7089
  • Fax: 773-296-7731
Mailing address:
  • Phone: 773-296-7089
  • Fax: 773-296-7731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209035144
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041443146
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: