Provider Demographics
NPI:1851708622
Name:COTEY, MARY CAROLYN (NP-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CAROLYN
Last Name:COTEY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3880 SALEM LAKE DR STE F
Mailing Address - Street 2:
Mailing Address - City:LONG GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60047-5292
Mailing Address - Country:US
Mailing Address - Phone:847-719-2220
Mailing Address - Fax:847-719-2265
Practice Address - Street 1:22285 N PEPPER RD STE 302
Practice Address - Street 2:
Practice Address - City:LAKE BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-2541
Practice Address - Country:US
Practice Address - Phone:847-726-0774
Practice Address - Fax:847-239-7919
Is Sole Proprietor?:No
Enumeration Date:2014-07-14
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209011613363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209011613Medicaid
ILMC3235618OtherDEA