Basic Information
Provider Information | |||||||||
NPI: | 1437441318 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARLISLE | ||||||||
FirstName: | MARY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | ANP-C, FNP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GEWARGIS | ||||||||
OtherFirstName: | MARY | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | ANP-C, FNP-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2050 CLAIRE CT | ||||||||
Address2: |   | ||||||||
City: | GLENVIEW | ||||||||
State: | IL | ||||||||
PostalCode: | 600257635 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8474677423 | ||||||||
FaxNumber: | 8475561715 | ||||||||
Practice Location | |||||||||
Address1: | 2050 CLAIRE CT | ||||||||
Address2: |   | ||||||||
City: | GLENVIEW | ||||||||
State: | IL | ||||||||
PostalCode: | 600257635 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8474677423 | ||||||||
FaxNumber: | 8475561715 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/10/2011 | ||||||||
LastUpdateDate: | 04/21/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 209008799 | IL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
ID | Type | State | Issuer | Description | 1437441318 | 01 | IL | NPI | OTHER |