Healthcare Provider Details

I. General information

NPI: 1346929601
Provider Name (Legal Business Name): LILLY H PARK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2023
Last Update Date: 07/13/2023
Certification Date: 07/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10604 SOUTHWEST HWY STE 200
CHICAGO RIDGE IL
60415-2717
US

IV. Provider business mailing address

16127 BENT GRASS DR
LOCKPORT IL
60441-4615
US

V. Phone/Fax

Practice location:
  • Phone: 708-424-9710
  • Fax:
Mailing address:
  • Phone: 708-253-5020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209027841
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: