MEDICARE: MS. LAUREN ELIZABETH FISHBACK APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	209016762	IL

General Provider Information

NPI Number	:	1255849030
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LAUREN ELIZABETH FISHBACK APRN

Provider Business Mailing Address
First Line	:	2333 W IRVING PARK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-3838
Country	:	US
Telephone Number	:	773-506-7340
Fax Number	:	773-506-7340

Provider Business Practice Location Address
First Line	:	2333 W IRVING PARK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-3838
Country	:	US
Telephone Number	:	773-506-7340
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/16/2018
Last Update Date	:	02/07/2018

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