Provider Demographics
NPI:1255779955
Name:LITTLEJOHN, MARY C (APN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:LITTLEJOHN
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 LINCOLN COURT PLACE
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-5372
Mailing Address - Country:US
Mailing Address - Phone:618-257-2029
Mailing Address - Fax:618-235-5371
Practice Address - Street 1:130 LINCOLN COURT PLACE
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62221-5372
Practice Address - Country:US
Practice Address - Phone:618-257-2029
Practice Address - Fax:618-235-5371
Is Sole Proprietor?:No
Enumeration Date:2013-06-05
Last Update Date:2017-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209010179363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health