Healthcare Provider Details

I. General information

NPI: 1992984975
Provider Name (Legal Business Name): MARILYN SNOOK P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2007
Last Update Date: 12/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 FRANKLIN AVE SUITE 230-C
NORMAL IL
61761-3588
US

IV. Provider business mailing address

901 MCCLINTOCK DR SUITE 202
BURR RIDGE IL
60527-0844
US

V. Phone/Fax

Practice location:
  • Phone: 888-220-6432
  • Fax: 309-268-2952
Mailing address:
  • Phone: 888-220-6432
  • Fax: 630-654-4253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085-003110
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: