Provider Demographics
NPI:1639415979
Name:JAMES, MARY SHIELLAH BLANCAFLOR (NP)
Entity Type:Individual
Prefix:
First Name:MARY SHIELLAH
Middle Name:BLANCAFLOR
Last Name:JAMES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SHIELLAH
Other - Middle Name:BLANCAFLOR
Other - Last Name:JAMES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:17808 S MCCARRON RD
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-9776
Mailing Address - Country:US
Mailing Address - Phone:708-825-7052
Mailing Address - Fax:
Practice Address - Street 1:6700 167TH ST STE 4
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-2078
Practice Address - Country:US
Practice Address - Phone:708-429-3700
Practice Address - Fax:708-429-4460
Is Sole Proprietor?:No
Enumeration Date:2012-12-13
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28227760A363LF0000X
IL277.000750363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily