Healthcare Provider Details

I. General information

NPI: 1740335975
Provider Name (Legal Business Name): MARY B. WELLS RN, MSN, LMT, AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 01/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11231 DISTINCTIVE DR
ORLAND PARK IL
60467-9458
US

IV. Provider business mailing address

11231 DISTINCTIVE DR
ORLAND PARK IL
60467-9458
US

V. Phone/Fax

Practice location:
  • Phone: 800-461-9533
  • Fax:
Mailing address:
  • Phone: 800-461-9533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209012826
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number209012826
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: