Provider Demographics
NPI:1235229469
Name:ATHA, MARY (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ATHA
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 1:2050 PFINGSTEN RD
Mailing Address - Street 2:STE 320
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-1324
Mailing Address - Country:US
Mailing Address - Phone:773-935-5556
Mailing Address - Fax:
Practice Address - Street 1:2800 N SHERIDAN RD
Practice Address - Street 2:SUITE 301
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6156
Practice Address - Country:US
Practice Address - Phone:773-935-5556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-002111363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209-002111OtherADVANCED PRACTICE NURSING
IL309-002181OtherSTATE CONTROLLED SUBSTANC
IL309-002181OtherSTATE CONTROLLED SUBSTANC
IL309-002181OtherSTATE CONTROLLED SUBSTANC