Basic Information
| Provider Information | |||||||||
| NPI: | 1255779955 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LITTLEJOHN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 LINCOLN COURT PLACE | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622215372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182572029 | ||||||||
| FaxNumber: | 6182355371 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 LINCOLN COURT PLACE | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622215372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182572029 | ||||||||
| FaxNumber: | 6182355371 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2013 | ||||||||
| LastUpdateDate: | 09/27/2017 | ||||||||
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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 | 363LA2200X | 209010179 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363L00000X | 209010179 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.