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General NPI Number Information
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NPI Number | 1235229469
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Entity Type | Individual
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Provider Name | MARY ATHA NP
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Gender | Female
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Dates
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Enumeration Date | 10/16/2006
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 2800 N SHERIDAN RD SUITE 301
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City | CHICAGO
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State | IL
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Zip | 60657-6156
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Country | US
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Telephone | 773-935-5556
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Fax |
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Provider Business Mailing Address
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Address Line | 2050 PFINGSTEN RD STE 320
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City | GLENVIEW
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State | IL
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Zip | 60026-1324
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Country | US
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Telephone | 773-935-5556
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 209-002111
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License Number State | IL
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