Healthcare Provider Details

I. General information

NPI: 1336429950
Provider Name (Legal Business Name): MARY A MARVIN ACNS BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2011
Last Update Date: 08/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 NE GLEN OAK AVE
PEORIA IL
61637-0001
US

IV. Provider business mailing address

100 APPELLATE CT
EAST PEORIA IL
61611-1402
US

V. Phone/Fax

Practice location:
  • Phone: 309-671-1539
  • Fax: 309-671-7528
Mailing address:
  • Phone: 309-698-1195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number041290023
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: