Healthcare Provider Details

I. General information

NPI: 1760413637
Provider Name (Legal Business Name): KERRY COLLINS LAZEWSKI NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2515 N CLARK ST
CHICAGO IL
60614-2730
US

IV. Provider business mailing address

220 DES PLAINES AVE UNIT E
FOREST PARK IL
60130-1227
US

V. Phone/Fax

Practice location:
  • Phone: 800-543-7365
  • Fax:
Mailing address:
  • Phone: 708-771-2747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number209005522
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: