Provider Demographics
NPI:1164190849
Name:LOBOS, MARIA NESSAN VENERABLE
Entity Type:Individual
Prefix:MRS
First Name:MARIA NESSAN
Middle Name:VENERABLE
Last Name:LOBOS
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 1:4141 N ROCKTON AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-1524
Mailing Address - Country:US
Mailing Address - Phone:815-316-1519
Mailing Address - Fax:
Practice Address - Street 1:2006 EVANS AVE
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-3235
Practice Address - Country:US
Practice Address - Phone:847-630-9010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1600074013225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant