Provider Demographics
NPI:1871042648
Name:ZIMMER, MARY (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ZIMMER
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 N 14TH ST
Mailing Address - Street 2:
Mailing Address - City:MURPHYSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62966-1807
Mailing Address - Country:US
Mailing Address - Phone:618-687-2353
Mailing Address - Fax:
Practice Address - Street 1:628 N 14TH ST
Practice Address - Street 2:
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-1807
Practice Address - Country:US
Practice Address - Phone:618-687-2353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-22
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-383418163W00000X
IL209015208363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse