Healthcare Provider Details

I. General information

NPI: 1760552582
Provider Name (Legal Business Name): MARY KAY AYERS CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 06/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ST. ANTHONY HOSPITAL 2875 W. 19TH STREET
CHICAGO IL
60623
US

IV. Provider business mailing address

PO BOX 465
ELWOOD IL
60421-0465
US

V. Phone/Fax

Practice location:
  • Phone: 773-484-4366
  • Fax:
Mailing address:
  • Phone: 815-423-5405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number209-004150
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: