1215456967 NPI number — MRS. MARTHA ELENA MCNAB FNP-C

Table of content: MRS. MARTHA ELENA MCNAB FNP-C (NPI 1215456967)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215456967 NPI number — MRS. MARTHA ELENA MCNAB FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCNAB
Provider First Name:
MARTHA
Provider Middle Name:
ELENA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215456967
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/09/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
634 POPLAR AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROMEOVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60446-1658
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-641-6927
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 N WINFIELD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINFIELD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60190-1295
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-933-4487
Provider Business Practice Location Address Fax Number:
630-933-2009
Provider Enumeration Date:
09/13/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  209016542 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: F400457151 . This is a "MEDICARE INDIVIDUAL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 206147 . This is a "MEDICARE GROUP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".