Provider Demographics
NPI:1225074495
Name:ELY, MARY (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ELY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SATTLEY ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:62563-9241
Mailing Address - Country:US
Mailing Address - Phone:217-789-3630
Mailing Address - Fax:
Practice Address - Street 1:300 SATTLEY ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:IL
Practice Address - Zip Code:62563-9241
Practice Address - Country:US
Practice Address - Phone:217-789-3630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277000332363L00000X
IL041259431363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL2868020Medicare PIN
ILQ68594Medicare UPIN
ILK27424Medicare ID - Type Unspecified
ILIL2868020Medicare PIN