Provider Demographics
NPI:1063176220
Name:HOLMSTROM, MARY MARLENE (MSN, APRN, WHNP-BC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:MARLENE
Last Name:HOLMSTROM
Suffix:
Gender:F
Credentials:MSN, APRN, WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 713260
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-1260
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:5201 WILLOW SPRINGS RD STE 490
Practice Address - Street 2:
Practice Address - City:LA GRANGE HIGHLANDS
Practice Address - State:IL
Practice Address - Zip Code:60525-6548
Practice Address - Country:US
Practice Address - Phone:708-352-4630
Practice Address - Fax:708-352-8348
Is Sole Proprietor?:No
Enumeration Date:2021-10-25
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.026895363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health