Provider Demographics
NPI:1366768764
Name:WELLES, MARY COLLEEN (APN)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:COLLEEN
Last Name:WELLES
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:676 N SAINT CLAIR ST
Mailing Address - Street 2:SUITE 2125
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2927
Mailing Address - Country:US
Mailing Address - Phone:312-926-5400
Mailing Address - Fax:312-926-8885
Practice Address - Street 1:676 N SAINT CLAIR ST
Practice Address - Street 2:SUITE 2125
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2927
Practice Address - Country:US
Practice Address - Phone:312-926-5400
Practice Address - Fax:312-926-8885
Is Sole Proprietor?:No
Enumeration Date:2010-04-12
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL209.002324364SX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SX0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistOncology