Provider Demographics
NPI:1306512843
Name:SERVANDE, MA RITZ (NP)
Entity type:Individual
Prefix:
First Name:MA RITZ
Middle Name:
Last Name:SERVANDE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 GREENLEAF DR
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60436-9722
Mailing Address - Country:US
Mailing Address - Phone:815-295-1451
Mailing Address - Fax:
Practice Address - Street 1:534 W CHESTNUT ST STE 100
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3175
Practice Address - Country:US
Practice Address - Phone:630-568-3382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209020131363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner