Provider Demographics
NPI:1740335975
Name:WELLS, MARY B (RN, MSN, LMT, AGNP-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:B
Last Name:WELLS
Suffix:
Gender:F
Credentials:RN, MSN, LMT, AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11231 DISTINCTIVE DR
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-9458
Mailing Address - Country:US
Mailing Address - Phone:800-461-9533
Mailing Address - Fax:
Practice Address - Street 1:11231 DISTINCTIVE DR
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-9458
Practice Address - Country:US
Practice Address - Phone:800-461-9533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209012826363LA2200X, 363LG0600X, 363LG0600X
IL041-203519163WM1400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM1400XNursing Service ProvidersRegistered NurseNurse Massage Therapist (NMT)
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology