Provider Demographics
NPI:1821628710
Name:DEMARCO, DESIRAE (APN)
Entity Type:Individual
Prefix:
First Name:DESIRAE
Middle Name:
Last Name:DEMARCO
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 1:941 WINTER PARK DR
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-3107
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10604 SOUTHWEST HWY STE 107
Practice Address - Street 2:
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-2717
Practice Address - Country:US
Practice Address - Phone:708-274-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-20
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209020312363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner