Provider Demographics
NPI:1104835495
Name:FREY, MARLISE (CNP)
Entity Type:Individual
Prefix:MRS
First Name:MARLISE
Middle Name:
Last Name:FREY
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1653 W CONGRESS PKWY
Mailing Address - Street 2:#348 MURDOCK
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3833
Mailing Address - Country:US
Mailing Address - Phone:312-942-5939
Mailing Address - Fax:312-942-2238
Practice Address - Street 1:1725 W HARRISON ST
Practice Address - Street 2:#1118
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3841
Practice Address - Country:US
Practice Address - Phone:312-942-5936
Practice Address - Fax:312-942-2380
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-000399363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL309-000238OtherCONTROLLED SUBSTANCE LICE
DCMF0706486OtherFED DRUG ENFORCEMENT AGEN
ILP45473Medicare UPIN