Provider Demographics
NPI:1245587898
Name:WERTZ, MARY BETH (RN)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:BETH
Last Name:WERTZ
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 N PRAIRIE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-7399
Mailing Address - Country:US
Mailing Address - Phone:815-370-9282
Mailing Address - Fax:
Practice Address - Street 1:100 N JEFFERY STREET
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901
Practice Address - Country:US
Practice Address - Phone:815-939-8501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-13
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.207211163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator