Provider Demographics
NPI:1649241951
Name:HOLLENKAMP, MARY (APN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:HOLLENKAMP
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 1:60 REGENCY PL
Mailing Address - Street 2:
Mailing Address - City:MILLSTADT
Mailing Address - State:IL
Mailing Address - Zip Code:62260-2210
Mailing Address - Country:US
Mailing Address - Phone:618-476-3373
Mailing Address - Fax:618-476-1890
Practice Address - Street 1:60 REGENCY PL
Practice Address - Street 2:
Practice Address - City:MILLSTADT
Practice Address - State:IL
Practice Address - Zip Code:62260-2210
Practice Address - Country:US
Practice Address - Phone:618-476-3373
Practice Address - Fax:618-476-1890
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001133363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208438Medicare ID - Type Unspecified
ILQ35530Medicare UPIN