Healthcare Provider Details

I. General information

NPI: 1124073713
Provider Name (Legal Business Name): LISA STUCKY-MARSHALL APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 03/10/2021
Certification Date: 03/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177 E BRUSH HILL RD
ELMHURST IL
60126
US

IV. Provider business mailing address

177 E BRUSH HILL RD
ELMHURST IL
60126-5658
US

V. Phone/Fax

Practice location:
  • Phone: 331-221-2161
  • Fax: 331-221-3857
Mailing address:
  • Phone: 331-221-2161
  • Fax: 331-221-3857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SX0200X
TaxonomyOncology Clinical Nurse Specialist
License Number209-002340
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209002340
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: