=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336429950
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY A MARVIN ACNS BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2011
-----------------------------------------------------
Last Update Date | 08/26/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 530 NE GLEN OAK AVE
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61637-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-671-1539
-----------------------------------------------------
Fax | 309-671-7528
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 APPELLATE CT
-----------------------------------------------------
City | EAST PEORIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61611-1402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-698-1195
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 364SA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Clinical Nurse Specialist
-----------------------------------------------------
License Number | 041290023
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------