Healthcare Provider Details

I. General information

NPI: 1902621980
Provider Name (Legal Business Name): LAKES HEALTH AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2024
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7227 STATE PARK RD
FOX LAKE IL
60020-1027
US

IV. Provider business mailing address

7227 STATE PARK RD
FOX LAKE IL
60020-1027
US

V. Phone/Fax

Practice location:
  • Phone: 815-363-2020
  • Fax: 949-703-8263
Mailing address:
  • Phone: 815-363-2020
  • Fax: 949-703-8263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY RAE GALLINA
Title or Position: FNP-C, CNM
Credential: FNP-C, CNM
Phone: 815-363-2020