Healthcare Provider Details

I. General information

NPI: 1700232733
Provider Name (Legal Business Name): LAUREN HARRIETT D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2016
Last Update Date: 03/14/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 N PARKSIDE AVE
CHICAGO IL
60644-3040
US

IV. Provider business mailing address

14 LAKE ST
OAK PARK IL
60302-2606
US

V. Phone/Fax

Practice location:
  • Phone: 773-295-3060
  • Fax: 773-295-3061
Mailing address:
  • Phone: 708-383-0113
  • Fax: 773-836-7381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberH63052587921
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036148337
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: