Healthcare Provider Details

I. General information

NPI: 1649783143
Provider Name (Legal Business Name): MARY JOYCE L. VENTOCILLA MSN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY JOYCE A LAGATAO

II. Dates (important events)

Enumeration Date: 11/07/2017
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4309 W MEDICAL CENTER DR STE B202
MCHENRY IL
60050-8417
US

IV. Provider business mailing address

4309 W MEDICAL CENTER DR STE B202
MCHENRY IL
60050-8417
US

V. Phone/Fax

Practice location:
  • Phone: 847-535-6083
  • Fax: 815-455-2789
Mailing address:
  • Phone: 847-535-6083
  • Fax: 815-455-2789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.016350
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209016350
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: