Provider Demographics
NPI:1942366588
Name:STOWELL, MARY IRENE (APRN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:IRENE
Last Name:STOWELL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:I
Other - Last Name:STOWELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:14044 W PETRONELLA DR STE 3
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-9656
Mailing Address - Country:US
Mailing Address - Phone:847-549-6044
Mailing Address - Fax:847-549-6058
Practice Address - Street 1:14044 W PETRONELLA DR STE 3
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-9656
Practice Address - Country:US
Practice Address - Phone:847-549-6044
Practice Address - Fax:847-549-6058
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209002150363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1174664882OtherPROACTIVE ALTERNATIVES PC