Provider Demographics
NPI:1467237354
Name:TACCONA, MARY (APRN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:TACCONA
Suffix:
Gender:F
Credentials:APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 LONGRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-1416
Mailing Address - Country:US
Mailing Address - Phone:630-991-7943
Mailing Address - Fax:
Practice Address - Street 1:1189 N GARY AVE
Practice Address - Street 2:
Practice Address - City:CAROL STREAM
Practice Address - State:IL
Practice Address - Zip Code:60188-9423
Practice Address - Country:US
Practice Address - Phone:630-517-5674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209026634363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily