Provider Demographics
NPI:1306203757
Name:MAYER-ZICH, SHELLEY K (APRN, CNP)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:K
Last Name:MAYER-ZICH
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12251 S 80TH AVE STE 1780
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1290
Mailing Address - Country:US
Mailing Address - Phone:708-923-4400
Mailing Address - Fax:708-923-4421
Practice Address - Street 1:12251 S 80TH AVE STE 1780
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1290
Practice Address - Country:US
Practice Address - Phone:708-923-4400
Practice Address - Fax:708-923-4421
Is Sole Proprietor?:No
Enumeration Date:2016-01-15
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209013775363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400397885OtherMEDICARE PTAN
ILF400397885OtherMEDICARE PTAN