Provider Demographics
NPI:1649783143
Name:VENTOCILLA, MARY JOYCE L (MSN, FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:MARY JOYCE
Middle Name:L
Last Name:VENTOCILLA
Suffix:
Gender:F
Credentials:MSN, FNP-BC
Other - Prefix:
Other - First Name:MARY JOYCE
Other - Middle Name:A
Other - Last Name:LAGATAO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4309 W MEDICAL CENTER DR STE B202
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-8417
Mailing Address - Country:US
Mailing Address - Phone:847-535-6083
Mailing Address - Fax:815-455-2789
Practice Address - Street 1:4309 W MEDICAL CENTER DR STE B202
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-8417
Practice Address - Country:US
Practice Address - Phone:847-535-6083
Practice Address - Fax:815-455-2789
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-07
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.016350363LF0000X
IL209016350363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily