Provider Demographics
NPI:1922016849
Name:PETRELLA, MARY THERESE (ND MS RN FNP BC)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:THERESE
Last Name:PETRELLA
Suffix:
Gender:F
Credentials:ND MS RN FNP BC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:THERESE
Other - Last Name:LAURIC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:24007 MAJESTIC DRIVE
Mailing Address - Street 2:
Mailing Address - City:MINOOKA
Mailing Address - State:IL
Mailing Address - Zip Code:60447
Mailing Address - Country:US
Mailing Address - Phone:815-467-2871
Mailing Address - Fax:
Practice Address - Street 1:2970 CHARTRES
Practice Address - Street 2:HYGIENIC INSTITUTE COMMUNITY HEALTH CLINIC
Practice Address - City:LA SALLE
Practice Address - State:IL
Practice Address - Zip Code:61301
Practice Address - Country:US
Practice Address - Phone:815-223-0196
Practice Address - Fax:815-223-0358
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL518740Medicare ID - Type Unspecified
S66588Medicare UPIN