Provider Demographics
NPI:1508070442
Name:ROYCE, MARY E (ACNP-BC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:ROYCE
Suffix:
Gender:F
Credentials:ACNP-BC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:E
Other - Last Name:HASKELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ACNP-BC
Mailing Address - Street 1:1025 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-2499
Mailing Address - Country:US
Mailing Address - Phone:217-528-7541
Mailing Address - Fax:
Practice Address - Street 1:1025 S 6TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-2403
Practice Address - Country:US
Practice Address - Phone:217-528-7541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-005642363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
IL522000004Medicare PIN