Provider Demographics
NPI:1437748852
Name:GRASSO, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:GRASSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 N SPRING AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60526-1475
Mailing Address - Country:US
Mailing Address - Phone:708-525-4065
Mailing Address - Fax:
Practice Address - Street 1:4254 W 55TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-4642
Practice Address - Country:US
Practice Address - Phone:773-582-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209022601363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics