1922016849 NPI number — MRS. MARY THERESE PETRELLA ND MS RN FNP BC

Table of content: MRS. MARY THERESE PETRELLA ND MS RN FNP BC (NPI 1922016849)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922016849 NPI number — MRS. MARY THERESE PETRELLA ND MS RN FNP BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETRELLA
Provider First Name:
MARY
Provider Middle Name:
THERESE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
ND MS RN FNP BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LAURIC
Provider Other First Name:
MARY
Provider Other Middle Name:
THERESE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1922016849
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24007 MAJESTIC DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINOOKA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-467-2871
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2970 CHARTRES
Provider Second Line Business Practice Location Address:
HYGIENIC INSTITUTE COMMUNITY HEALTH CLINIC
Provider Business Practice Location Address City Name:
LA SALLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-223-0196
Provider Business Practice Location Address Fax Number:
815-223-0358
Provider Enumeration Date:
08/04/2006

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: 363L00000X , 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)





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