Individual
MARY ATHA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
NP
Contact information
Practice address
2800 N SHERIDAN RD, SUITE 301, CHICAGO, IL 60657-6156
(773) 935-5556
Mailing address
2050 PFINGSTEN RD, STE 320, GLENVIEW, IL 60026-1324
(773) 935-5556
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
209-002111
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
209-002111
ADVANCED PRACTICE NURSING
IL
01
—
309-002181
STATE CONTROLLED SUBSTANC
IL
Enumeration date
10/16/2006
Last updated
03/07/2023
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