Provider Demographics
NPI:1336472836
Name:TAYLOR, MARY L (APN)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:L
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 N WINCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5265
Mailing Address - Country:US
Mailing Address - Phone:773-250-1078
Mailing Address - Fax:773-250-0497
Practice Address - Street 1:4501 N WINCHESTER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5265
Practice Address - Country:US
Practice Address - Phone:773-250-1078
Practice Address - Fax:773-250-0497
Is Sole Proprietor?:No
Enumeration Date:2009-09-15
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209004290363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health