Healthcare Provider Details

I. General information

NPI: 1750201497
Provider Name (Legal Business Name): LAURENCIA OUEDRAOGO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 W HARRISON ST
CHICAGO IL
60612-3801
US

IV. Provider business mailing address

3555 W LYNDALE ST UNIT 1D
CHICAGO IL
60647-3562
US

V. Phone/Fax

Practice location:
  • Phone: 312-902-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License Number041517562
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: