Healthcare Provider Details

I. General information

NPI: 1548538622
Provider Name (Legal Business Name): LAUREN ELIZABETH GARDSTROM APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2011
Last Update Date: 11/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2656 N ELSTON AVE
CHICAGO IL
60647-2019
US

IV. Provider business mailing address

2333 W SAINT PAUL AVE APT 212
CHICAGO IL
60647-5388
US

V. Phone/Fax

Practice location:
  • Phone: 773-252-1994
  • Fax:
Mailing address:
  • Phone: 219-688-2970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209009248
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209009248
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: