Healthcare Provider Details

I. General information

NPI: 1811138944
Provider Name (Legal Business Name): MARY E WASSILAK WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2009
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 DELNOR DR STE 204
GENEVA IL
60134-4226
US

IV. Provider business mailing address

351 DELNOR DR STE 204
GENEVA IL
60134-4226
US

V. Phone/Fax

Practice location:
  • Phone: 630-208-0784
  • Fax: 630-938-9190
Mailing address:
  • Phone: 630-208-0784
  • Fax: 630-938-9190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209006774
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number209.006774
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number209006774
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: