Healthcare Provider Details

I. General information

NPI: 1972584423
Provider Name (Legal Business Name): TERRI LYNNE O'MALLEY J.D., M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TERRI LYNNE VAN ZANDT

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5615 IRISH LANE
HARVARD IL
60033
US

IV. Provider business mailing address

5615 IRISH LANE
HARVARD IL
60033
US

V. Phone/Fax

Practice location:
  • Phone: 815-245-1502
  • Fax: 815-943-2848
Mailing address:
  • Phone: 815-245-1502
  • Fax: 815-943-2848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036 095762
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: