Provider Demographics
NPI:1598811994
Name:DEWBERRY-LAIT, MARY CLAIRE (NP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:CLAIRE
Last Name:DEWBERRY-LAIT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-3500
Mailing Address - Country:US
Mailing Address - Phone:847-390-5900
Mailing Address - Fax:
Practice Address - Street 1:1875 DEMPSTER ST STE 180
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1144
Practice Address - Country:US
Practice Address - Phone:844-725-5238
Practice Address - Fax:847-723-2791
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209003909363LF0000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041235354Medicaid
406120108OtherPTAN
406120108OtherPTAN
ILK47245Medicare UPIN
ILK47244Medicare UPIN