Healthcare Provider Details

I. General information

NPI: 1255849030
Provider Name (Legal Business Name): LAUREN ELIZABETH FISHBACK APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2018
Last Update Date: 02/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2333 W IRVING PARK RD
CHICAGO IL
60618-3838
US

IV. Provider business mailing address

2333 W IRVING PARK RD
CHICAGO IL
60618-3838
US

V. Phone/Fax

Practice location:
  • Phone: 773-506-7340
  • Fax:
Mailing address:
  • Phone: 773-506-7340
  • Fax: 773-506-7340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209016762
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: