Healthcare Provider Details

I. General information

NPI: 1942626577
Provider Name (Legal Business Name): MARY BAKER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2014
Last Update Date: 05/17/2022
Certification Date: 05/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 BRANDING AVE STE 310
DOWNERS GROVE IL
60515-5624
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-5624
US

V. Phone/Fax

Practice location:
  • Phone: 630-829-1038
  • Fax:
Mailing address:
  • Phone: 847-390-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.010902
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: