Provider Demographics
NPI:1982903852
Name:MORTLOCK, MARY MARGARET (CPNP, IBCLC)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:MARGARET
Last Name:MORTLOCK
Suffix:
Gender:F
Credentials:CPNP, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1389 ALBERTA CT
Mailing Address - Street 2:
Mailing Address - City:GLENDALE HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60139-3306
Mailing Address - Country:US
Mailing Address - Phone:630-858-5570
Mailing Address - Fax:
Practice Address - Street 1:2500 W HIGGINS RD STE 670
Practice Address - Street 2:
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60169-7208
Practice Address - Country:US
Practice Address - Phone:847-884-7710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-17
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.003557363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics