Provider Demographics
NPI:1578579470
Name:LEWIS, MARY ELIZABETH (C-FNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:LEWIS
Suffix:
Gender:F
Credentials:C-FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 RELIABLE PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0001
Mailing Address - Country:US
Mailing Address - Phone:309-672-4809
Mailing Address - Fax:
Practice Address - Street 1:214 NE GLEN OAK AVE
Practice Address - Street 2:SUITE 605
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-4309
Practice Address - Country:US
Practice Address - Phone:309-672-4603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL563097OtherHEALTHLINK
IL069915OtherHEALTH ALLIANCE
ILIL01Q8OtherJOHN DEERE
IL7215059OtherBCBS PPO
IL069915OtherHEALTH ALLIANCE
ILIL01Q8OtherJOHN DEERE