1023776622 NPI number — MRS. MARY LOUISE MCWETHY NP-C

Table of content: MRS. MARY LOUISE MCWETHY NP-C (NPI 1023776622)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023776622 NPI number — MRS. MARY LOUISE MCWETHY NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCWETHY
Provider First Name:
MARY
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NP-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:
1023776622
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1115 WHITE ROCK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DIXON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61021-9050
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-440-7901
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5200 HAHNS PEAK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOVELAND
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80538-8852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-920-2997
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/01/2021

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:  209023913 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X , with the licence number: APN.0999064-NP , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: APN.0999064-NP , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163W00000X , with the licence number: 041.406026 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 209023913 . This is a "APRN LICENSE NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".