Healthcare Provider Details

I. General information

NPI: 1598811994
Provider Name (Legal Business Name): MARY CLAIRE DEWBERRY-LAIT NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 03/10/2023
Certification Date: 03/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1875 DEMPSTER ST STE 180
PARK RIDGE IL
60068-1144
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-3500
US

V. Phone/Fax

Practice location:
  • Phone: 844-725-5238
  • Fax: 847-723-2791
Mailing address:
  • Phone: 847-390-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209003909
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209003909
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: