Healthcare Provider Details

I. General information

NPI: 1487106647
Provider Name (Legal Business Name): MARY KIRBY RN APN CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2016
Last Update Date: 11/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 E HURON ST
CHICAGO IL
60611-2908
US

IV. Provider business mailing address

9213 KYLEMORE CT
TINLEY PARK IL
60487-4794
US

V. Phone/Fax

Practice location:
  • Phone: 312-926-6421
  • Fax:
Mailing address:
  • Phone: 708-516-2763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2100X
TaxonomyAcute Care Clinical Nurse Specialist
License Number209001688
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: