Healthcare Provider Details

I. General information

NPI: 1265804967
Provider Name (Legal Business Name): MARY ANNETTE MURTAUGH APN-FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2015
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 EXECUTIVE PKWY STE 1
ROCKFORD IL
61107-5340
US

IV. Provider business mailing address

19990 GOVERNORS HWY
OLYMPIA FIELDS IL
60461-1021
US

V. Phone/Fax

Practice location:
  • Phone: 877-692-8686
  • Fax: 815-490-1625
Mailing address:
  • Phone: 708-747-7168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209013464
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: