Provider Demographics
NPI:1063461887
Name:THE LITTLE CLINIC ILLINOIS
Entity Type:Organization
Organization Name:THE LITTLE CLINIC ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:CAY
Authorized Official - Last Name:DECLUE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:618-246-9969
Mailing Address - Street 1:415 S 42ND ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6266
Mailing Address - Country:US
Mailing Address - Phone:618-246-9969
Mailing Address - Fax:
Practice Address - Street 1:415 S 42ND ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6266
Practice Address - Country:US
Practice Address - Phone:618-246-9969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213250Medicare ID - Type Unspecified