Basic Information
| Provider Information | |||||||||
| NPI: | 1598811994 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEWBERRY-LAIT | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | CLAIRE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2740 W FOSTER AVE | ||||||||
| Address2: | LL7 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606253500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7738788200 | ||||||||
| FaxNumber: | 7732934197 | ||||||||
| Practice Location | |||||||||
| Address1: | 5145 N CALIFORNIA AVE | ||||||||
| Address2: | STE. 272 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606253661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7738788200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2007 | ||||||||
| LastUpdateDate: | 01/22/2017 | ||||||||
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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 | 209003909 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LF0000X | 209003909 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 041235354 | 05 | IL | MEDICAID | 406120108 | 01 | PTAN | OTHER |