Basic Information
| Provider Information | |||||||||
| NPI: | 1578579470 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | C-FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5100 RELIABLE PKWY | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606860001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096724809 | ||||||||
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| Practice Location | |||||||||
| Address1: | 214 NE GLEN OAK AVE | ||||||||
| Address2: | SUITE 605 | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616034309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096724603 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 563097 | 01 | IL | HEALTHLINK | OTHER | 069915 | 01 | IL | HEALTH ALLIANCE | OTHER | IL01Q8 | 01 | IL | JOHN DEERE | OTHER | 7215059 | 01 | IL | BCBS PPO | OTHER |