Provider Demographics
NPI:1225397268
Name:GUEVARA, MARY-JENNELLE
Entity Type:Individual
Prefix:
First Name:MARY-JENNELLE
Middle Name:
Last Name:GUEVARA
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 1:1875 DEMPSTER ST
Mailing Address - Street 2:SUITE 180
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1186
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1875 DEMPSTER ST
Practice Address - Street 2:SUITE 180
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1186
Practice Address - Country:US
Practice Address - Phone:847-897-9010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-11
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009523363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care