Provider Demographics
NPI:1215019666
Name:ZERVAKIS-BRENT, MARY ANN
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:ZERVAKIS-BRENT
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 1:1740 W TAYLOR ST
Mailing Address - Street 2:3RD FLOOR - 3200W, MC515
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-7232
Mailing Address - Country:US
Mailing Address - Phone:312-996-4020
Mailing Address - Fax:312-996-4019
Practice Address - Street 1:1740 W TAYLOR ST
Practice Address - Street 2:3RD FLOOR - 3200W, MC515
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7232
Practice Address - Country:US
Practice Address - Phone:312-996-4020
Practice Address - Fax:312-996-4019
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041253437363L00000X
IL209005895367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner