Healthcare Provider Details

I. General information

NPI: 1982990149
Provider Name (Legal Business Name): MARIE RODRIGUEZ RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2011
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4318 S STATE ST
CHICAGO IL
60609-3701
US

IV. Provider business mailing address

PO BOX 746721
ATLANTA GA
30374-6721
US

V. Phone/Fax

Practice location:
  • Phone: 773-285-9304
  • Fax:
Mailing address:
  • Phone: 733-521-5157
  • Fax: 312-929-0373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number71005662
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number71005662
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number209.025497
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: