Provider Demographics
NPI:1124579099
Name:BROOKS, MARY (APRN-FPA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BROOKS
Suffix:
Gender:
Credentials:APRN-FPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25870 HETTICK SCOTTVILLE RD
Mailing Address - Street 2:
Mailing Address - City:HETTICK
Mailing Address - State:IL
Mailing Address - Zip Code:62649-4791
Mailing Address - Country:US
Mailing Address - Phone:217-416-0641
Mailing Address - Fax:
Practice Address - Street 1:25870 HETTICK SCOTTVILLE RD
Practice Address - Street 2:
Practice Address - City:HETTICK
Practice Address - State:IL
Practice Address - Zip Code:62649-4791
Practice Address - Country:US
Practice Address - Phone:217-416-0641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-17
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209016051363LF0000X
IL277002936363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily