Healthcare Provider Details

I. General information

NPI: 1316978992
Provider Name (Legal Business Name): MARIA B BROADSTREET CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 W 95TH ST STE 106
OAK LAWN IL
60453-2656
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-3717
US

V. Phone/Fax

Practice location:
  • Phone: 708-684-5580
  • Fax: 708-684-4068
Mailing address:
  • Phone: 847-390-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209004364
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number209004364
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: