Provider Demographics
NPI:1417765694
Name:WEEG, MARY ELLEN (AGCNS-BC)
Entity type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:WEEG
Suffix:
Gender:F
Credentials:AGCNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 SILVER CROSS BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-9508
Mailing Address - Country:US
Mailing Address - Phone:815-300-5783
Mailing Address - Fax:815-485-4830
Practice Address - Street 1:1850 SILVER CROSS BLVD
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-9508
Practice Address - Country:US
Practice Address - Phone:815-300-5783
Practice Address - Fax:815-485-4830
Is Sole Proprietor?:No
Enumeration Date:2024-12-20
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL309.021859364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist