Healthcare Provider Details

I. General information

NPI: 1487573937
Provider Name (Legal Business Name): KATLIN MELISSA LAKOTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

781 S MCHENRY AVE STE D
CRYSTAL LAKE IL
60014-7444
US

IV. Provider business mailing address

781 S MCHENRY AVE STE D
CRYSTAL LAKE IL
60014-7444
US

V. Phone/Fax

Practice location:
  • Phone: 815-459-2200
  • Fax:
Mailing address:
  • Phone: 815-459-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.036042
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: