Provider Demographics
NPI:1265962336
Name:GOLEMBECK, MARY (FNP-BC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:GOLEMBECK
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:985 LIST LN
Mailing Address - Street 2:
Mailing Address - City:BELVIDERE
Mailing Address - State:IL
Mailing Address - Zip Code:61008-1520
Mailing Address - Country:US
Mailing Address - Phone:937-564-3178
Mailing Address - Fax:
Practice Address - Street 1:7290 ARGUS DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107
Practice Address - Country:US
Practice Address - Phone:815-394-1530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-12
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.023143363LP2300X
IL209015966363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care