Provider Demographics
NPI:1811138944
Name:WASSILAK, MARY E (WHNP-BC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:WASSILAK
Suffix:
Gender:F
Credentials:WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 DELNOR DR STE 204
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-4226
Mailing Address - Country:US
Mailing Address - Phone:630-208-0784
Mailing Address - Fax:630-938-9190
Practice Address - Street 1:351 DELNOR DR STE 204
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-4226
Practice Address - Country:US
Practice Address - Phone:630-208-0784
Practice Address - Fax:630-938-9190
Is Sole Proprietor?:No
Enumeration Date:2009-03-19
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.006774363LW0102X
IL209006774363LX0001X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology