Basic Information
| Provider Information | |||||||||
| NPI: | 1104835495 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FREY | ||||||||
| FirstName: | MARLISE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1653 W CONGRESS PKWY | ||||||||
| Address2: | #348 MURDOCK | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606123833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129425939 | ||||||||
| FaxNumber: | 3129422238 | ||||||||
| Practice Location | |||||||||
| Address1: | 1725 W HARRISON ST | ||||||||
| Address2: | #1118 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606123841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129425936 | ||||||||
| FaxNumber: | 3129422380 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 01/27/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209-000399 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 309-000238 | 01 | IL | CONTROLLED SUBSTANCE LICE | OTHER | MF0706486 | 01 | DC | FED DRUG ENFORCEMENT AGEN | OTHER |