Provider Demographics
NPI:1063183929
Name:PURDOM, MACEY
Entity type:Individual
Prefix:
First Name:MACEY
Middle Name:
Last Name:PURDOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-5363
Mailing Address - Country:US
Mailing Address - Phone:210-380-3080
Mailing Address - Fax:
Practice Address - Street 1:12890 HILLCREST RD STE 203
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-6562
Practice Address - Country:US
Practice Address - Phone:972-239-2777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-21
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1052508363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health