Healthcare Provider Details

I. General information

NPI: 1962189845
Provider Name (Legal Business Name): ZACHARY SCOTT LYTH NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2023
Last Update Date: 09/08/2023
Certification Date: 09/07/2023
Deactivation Date: 08/30/2023
Reactivation Date: 09/06/2023

III. Provider practice location address

5645 W ADDISON ST
CHICAGO IL
60634-4403
US

IV. Provider business mailing address

2426 CUYLER AVE
BERWYN IL
60402-2616
US

V. Phone/Fax

Practice location:
  • Phone: 773-282-7000
  • Fax:
Mailing address:
  • Phone: 630-835-6976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number209028199
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: