Provider Demographics
NPI:1710236815
Name:DE LA PAZ, MARISSA (ANP)
Entity Type:Individual
Prefix:MISS
First Name:MARISSA
Middle Name:
Last Name:DE LA PAZ
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 E WOODFIELD RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-4836
Mailing Address - Country:US
Mailing Address - Phone:847-605-0030
Mailing Address - Fax:847-637-0737
Practice Address - Street 1:804 E. WOODFIELD ROAD
Practice Address - Street 2:300
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60173
Practice Address - Country:US
Practice Address - Phone:847-605-9500
Practice Address - Fax:847-605-8700
Is Sole Proprietor?:No
Enumeration Date:2012-09-05
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009695363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
ILIL1648011Medicare PIN