Provider Demographics
NPI:1104545482
Name:NEVILLE, MARY (DNP, CPNP-AC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:NEVILLE
Suffix:
Gender:F
Credentials:DNP, CPNP-AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 E 2150 NORTH RD
Mailing Address - Street 2:
Mailing Address - City:DANVERS
Mailing Address - State:IL
Mailing Address - Zip Code:61732-9018
Mailing Address - Country:US
Mailing Address - Phone:309-267-8760
Mailing Address - Fax:
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-0001
Practice Address - Country:US
Practice Address - Phone:309-267-8760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.025804363LP0222X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care