Healthcare Provider Details

I. General information

NPI: 1174537880
Provider Name (Legal Business Name): LOLA M. DIXON APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5TH AVE SCI 128
HINES VA IL
60141
US

IV. Provider business mailing address

6939 97TH ST
CHICAGO RIDGE IL
60415-1187
US

V. Phone/Fax

Practice location:
  • Phone: 707-202-2702
  • Fax: 707-202-7960
Mailing address:
  • Phone: 708-233-9883
  • Fax: 708-202-7960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: