Healthcare Provider Details

I. General information

NPI: 1508219361
Provider Name (Legal Business Name): MARA LAYNE BESSINE NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2016
Last Update Date: 07/07/2020
Certification Date: 07/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 E PENN AVE
ROSEVILLE IL
61473-5006
US

IV. Provider business mailing address

113 S MAIN ST
SHEFFIELD IL
61361-9752
US

V. Phone/Fax

Practice location:
  • Phone: 309-426-2128
  • Fax: 309-426-2455
Mailing address:
  • Phone: 815-454-2811
  • Fax: 815-454-2832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209014465
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: