Healthcare Provider Details

I. General information

NPI: 1184188005
Provider Name (Legal Business Name): LISA ANN WALDROUP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2019
Last Update Date: 01/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1633 TINA LN
FLOSSMOOR IL
60422-1952
US

IV. Provider business mailing address

1633 TINA LN
FLOSSMOOR IL
60422-1952
US

V. Phone/Fax

Practice location:
  • Phone: 708-922-1344
  • Fax:
Mailing address:
  • Phone: 708-922-1344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number07483562
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number043.1161135
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: