Provider Demographics
NPI:1467224113
Name:NEMETH, MANDIE L
Entity Type:Individual
Prefix:
First Name:MANDIE
Middle Name:L
Last Name:NEMETH
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 1:1530 N RANDALL RD STE 210
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-7879
Mailing Address - Country:US
Mailing Address - Phone:224-760-7322
Mailing Address - Fax:224-535-8252
Practice Address - Street 1:1530 N RANDALL RD STE 210
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-7879
Practice Address - Country:US
Practice Address - Phone:224-760-7322
Practice Address - Fax:224-535-8252
Is Sole Proprietor?:No
Enumeration Date:2023-10-26
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209028463363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner