Provider Demographics
NPI:1528520665
Name:IBE, MARK RON SR (MSN, APRN, FNP-C)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:RON
Last Name:IBE
Suffix:SR
Gender:M
Credentials:MSN, APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9124 S SOMERSET LN
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-7587
Mailing Address - Country:US
Mailing Address - Phone:630-699-0911
Mailing Address - Fax:
Practice Address - Street 1:6325 MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-1357
Practice Address - Country:US
Practice Address - Phone:630-541-6773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-05
Last Update Date:2020-01-13
Deactivation Date:2019-07-24
Deactivation Code:
Reactivation Date:2019-12-11
Provider Licenses
StateLicense IDTaxonomies
IL209.018841363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily