Healthcare Provider Details

I. General information

NPI: 1740854330
Provider Name (Legal Business Name): LAURA ASHLEY EULITZ APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2021
Last Update Date: 06/30/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1890 SILVER CROSS BLVD STE 240
NEW LENOX IL
60451-9528
US

IV. Provider business mailing address

PO BOX 713260
CHICAGO IL
60677-1260
US

V. Phone/Fax

Practice location:
  • Phone: 815-740-1900
  • Fax: 815-485-4469
Mailing address:
  • Phone: 630-469-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209023872
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041430943
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: