Healthcare Provider Details

I. General information

NPI: 1104545482
Provider Name (Legal Business Name): MARY NEVILLE DNP, CPNP-AC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2022
Last Update Date: 08/22/2022
Certification Date: 07/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 NE GLEN OAK AVE
PEORIA IL
61637-0001
US

IV. Provider business mailing address

945 E 2150 NORTH RD
DANVERS IL
61732-9018
US

V. Phone/Fax

Practice location:
  • Phone: 309-267-8760
  • Fax:
Mailing address:
  • Phone: 309-267-8760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number209.025804
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: