Provider Demographics
NPI:1235271941
Name:ANTMAN, MARIELLEN PATRICIA (APN-CNP)
Entity Type:Individual
Prefix:
First Name:MARIELLEN
Middle Name:PATRICIA
Last Name:ANTMAN
Suffix:
Gender:F
Credentials:APN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 E HURON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2908
Mailing Address - Country:US
Mailing Address - Phone:847-735-8550
Mailing Address - Fax:847-535-8590
Practice Address - Street 1:800 N WESTMORELAND RD
Practice Address - Street 2:SUITE 205
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1673
Practice Address - Country:US
Practice Address - Phone:847-735-8550
Practice Address - Fax:847-535-8590
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041202000163W00000X
IL209005116363L00000X
IL209.005116363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL6304003OtherMEDICARE PTAN LOC 16
ILIL6305003OtherMEDICARE PTAN LOC 15
IL1720371669OtherNPI GROUP PRACTICE
ILP01058711OtherRRMC PTAN