Provider Demographics
NPI:1225786825
Name:FAIR, MARY GRACE (APRN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:GRACE
Last Name:FAIR
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:GRACE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1438 W BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-2150
Mailing Address - Country:US
Mailing Address - Phone:312-508-3645
Mailing Address - Fax:312-971-8554
Practice Address - Street 1:1438 W BELMONT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-2150
Practice Address - Country:US
Practice Address - Phone:312-508-3645
Practice Address - Fax:312-971-8554
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.546416163W00000X
IL209.028777363LP0808X
NC328533163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered Nurse