Provider Demographics
NPI:1639363476
Name:VANCE, MARY (APN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:VANCE
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 BIESTERFIELD RD
Mailing Address - Street 2:SUITE 510
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3361
Mailing Address - Country:US
Mailing Address - Phone:847-981-3660
Mailing Address - Fax:847-956-5108
Practice Address - Street 1:800 BIESTERFIELD RD
Practice Address - Street 2:SUITE 510
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3361
Practice Address - Country:US
Practice Address - Phone:847-981-3660
Practice Address - Fax:847-956-5108
Is Sole Proprietor?:No
Enumeration Date:2007-09-05
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209006626364SA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK45429Medicare PIN
IL209308001Medicare PIN