Provider Demographics
NPI:1972590719
Name:PRYKA, MARY L (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:PRYKA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25070 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1250
Mailing Address - Country:US
Mailing Address - Phone:847-585-7000
Mailing Address - Fax:847-240-0622
Practice Address - Street 1:8915 W GOLF RD
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-5905
Practice Address - Country:US
Practice Address - Phone:847-827-9060
Practice Address - Fax:847-827-7196
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-05
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209004174363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208179OtherMEDICARE PTAN
IL208179OtherMEDICARE PTAN
ILK05870Medicare ID - Type Unspecified