Provider Demographics
NPI:1063836450
Name:CRISLER, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:CRISLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 E LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-3810
Mailing Address - Country:US
Mailing Address - Phone:217-464-2540
Mailing Address - Fax:
Practice Address - Street 1:1800 E LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3810
Practice Address - Country:US
Practice Address - Phone:217-464-2540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.010845363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health