Healthcare Provider Details

I. General information

NPI: 1194134387
Provider Name (Legal Business Name): LINA NIAURIENE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2014
Last Update Date: 08/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6810 JOLIET RD APT 9
INDIAN HEAD PARK IL
60525-9018
US

IV. Provider business mailing address

6810 JOLIET RD APT 9
INDIAN HEAD PARK IL
60525-9018
US

V. Phone/Fax

Practice location:
  • Phone: 847-693-0637
  • Fax:
Mailing address:
  • Phone: 847-693-0637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number227.004117
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: