Healthcare Provider Details

I. General information

NPI: 1790062032
Provider Name (Legal Business Name): LAURIE A STEWART WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2011
Last Update Date: 04/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 SOUTH WILLOW SRINGS ROAD STE 490
LAGRANGE IL
60525-6548
US

IV. Provider business mailing address

5201 SOUTH WILLOW SRINGS ROAD STE 490
LAGRANGE IL
60525
US

V. Phone/Fax

Practice location:
  • Phone: 708-352-4630
  • Fax:
Mailing address:
  • Phone: 708-352-4630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number209.003350
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: