Provider Demographics
NPI:1255454278
Name:COURTNEY, MARY CATHERINE (RN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:CATHERINE
Last Name:COURTNEY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2384 KNOX ROAD 165 E
Mailing Address - Street 2:
Mailing Address - City:RIO
Mailing Address - State:IL
Mailing Address - Zip Code:61472-9736
Mailing Address - Country:US
Mailing Address - Phone:309-343-0733
Mailing Address - Fax:
Practice Address - Street 1:2323 WINDISH DR
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-9780
Practice Address - Country:US
Practice Address - Phone:309-344-4255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-282203163WP0808X, 163W00000X, 163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041-282203OtherSTATE LICENSE
IL370984175OtherFEIN BWAY INC