Provider Demographics
NPI:1316978992
Name:BROADSTREET, MARIA B (CPNP)
Entity type:Individual
Prefix:MS
First Name:MARIA
Middle Name:B
Last Name:BROADSTREET
Suffix:
Gender:
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-3717
Mailing Address - Country:US
Mailing Address - Phone:847-390-5900
Mailing Address - Fax:
Practice Address - Street 1:4400 W 95TH ST STE 106
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2656
Practice Address - Country:US
Practice Address - Phone:708-684-5580
Practice Address - Fax:708-684-4068
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209004364363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics