Healthcare Provider Details

I. General information

NPI: 1922315126
Provider Name (Legal Business Name): LISA A BENNETT NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LISA KEYS NURSE PRACTITIONER

II. Dates (important events)

Enumeration Date: 09/09/2010
Last Update Date: 12/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E CHICAGO AVE
CHICAGO IL
60611
US

IV. Provider business mailing address

4012 S INDIANA AVE UNIT 1N
CHICAGO IL
60653
US

V. Phone/Fax

Practice location:
  • Phone: 312-227-6090
  • Fax: 312-227-9403
Mailing address:
  • Phone: 773-880-4757
  • Fax: 773-880-3208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number209.008268
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: