Healthcare Provider Details

I. General information

NPI: 1952653438
Provider Name (Legal Business Name): MARY C HEWITT APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2012
Last Update Date: 11/20/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13011 S 104TH AVE STE 100
PALOS PARK IL
60464-1508
US

IV. Provider business mailing address

13011 S 104TH AVE STE 100
PALOS PARK IL
60464-1508
US

V. Phone/Fax

Practice location:
  • Phone: 708-274-3278
  • Fax:
Mailing address:
  • Phone: 708-274-3278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209.009808041.249554
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: