Provider Demographics
NPI:1861999344
Name:STREET, MARCIA ANN (FNP-C)
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:ANN
Last Name:STREET
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S SCOTT AVE
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:IL
Mailing Address - Zip Code:62448-1665
Mailing Address - Country:US
Mailing Address - Phone:618-783-2144
Mailing Address - Fax:618-783-2541
Practice Address - Street 1:500 S SCOTT AVE
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:IL
Practice Address - Zip Code:62448-1665
Practice Address - Country:US
Practice Address - Phone:618-783-2144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.018377207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine