Healthcare Provider Details

I. General information

NPI: 1083007199
Provider Name (Legal Business Name): JOANNA LYSZKOWSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2015
Last Update Date: 03/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9822 N MAYNARD TER
NILES IL
60714-1031
US

IV. Provider business mailing address

9822 N MAYNARD TER
NILES IL
60714-1031
US

V. Phone/Fax

Practice location:
  • Phone: 847-644-2237
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: