Provider Demographics
NPI:1427789783
Name:KISCELLUS, MAYRA (FNP-BC)
Entity type:Individual
Prefix:
First Name:MAYRA
Middle Name:
Last Name:KISCELLUS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 W HIGGINS RD STE 140
Mailing Address - Street 2:
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60169-2422
Mailing Address - Country:US
Mailing Address - Phone:847-781-3100
Mailing Address - Fax:847-781-5156
Practice Address - Street 1:2350 ROYAL BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-4718
Practice Address - Country:US
Practice Address - Phone:847-695-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-17
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041381391163W00000X
IL209-05861363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse