Basic Information
| Provider Information | |||||||||
| NPI: | 1972590719 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRYKA | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25070 NETWORK PL | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606731250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475857000 | ||||||||
| FaxNumber: | 8472400622 | ||||||||
| Practice Location | |||||||||
| Address1: | 8915 W GOLF RD | ||||||||
| Address2: | |||||||||
| City: | NILES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 607145905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478279060 | ||||||||
| FaxNumber: | 8478277196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2005 | ||||||||
| LastUpdateDate: | 12/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209004174 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 208179 | 01 | IL | MEDICARE PTAN | OTHER |