Provider Demographics
NPI:1952315582
Name:GAWNE, MARY KAY (APN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KAY
Last Name:GAWNE
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KAY
Other - Last Name:BARRON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN, CNP
Mailing Address - Street 1:20 S CLARK ST
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60603-1802
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 S CLARK ST
Practice Address - Street 2:SUITE 1100
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60603-1802
Practice Address - Country:US
Practice Address - Phone:312-926-7443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-001604363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036071152Medicaid