Healthcare Provider Details

I. General information

NPI: 1134888480
Provider Name (Legal Business Name): SHALANDA LEWIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2021
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12863 S NORMAL AVE
CHICAGO IL
60628-7436
US

IV. Provider business mailing address

16029 UNIVERSITY AVE
SOUTH HOLLAND IL
60473-1766
US

V. Phone/Fax

Practice location:
  • Phone: 312-479-1530
  • Fax: 312-479-1530
Mailing address:
  • Phone: 312-479-1530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number14D2245600
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: