Provider Demographics
NPI:1003822552
Name:LETIZIA, MARIJO (ANP)
Entity Type:Individual
Prefix:
First Name:MARIJO
Middle Name:
Last Name:LETIZIA
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:457 S PARKVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-4112
Mailing Address - Country:US
Mailing Address - Phone:708-216-9325
Mailing Address - Fax:708-216-9555
Practice Address - Street 1:512 E OGDEN AVE
Practice Address - Street 2:
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559-1228
Practice Address - Country:US
Practice Address - Phone:630-323-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-00538363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0032243774OtherBCBS PROVIDER NUMBER