Healthcare Provider Details

I. General information

NPI: 1700128113
Provider Name (Legal Business Name): LIA N WRENN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2013
Last Update Date: 02/28/2022
Certification Date: 02/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1645 W JACKSON BLVD STE 310
CHICAGO IL
60612-3227
US

IV. Provider business mailing address

1645 W JACKSON BLVD STE 310
CHICAGO IL
60612-3227
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-8060
  • Fax:
Mailing address:
  • Phone: 312-942-8060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number042.0013744
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036155388
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number279519
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: