Healthcare Provider Details

I. General information

NPI: 1063990588
Provider Name (Legal Business Name): LISA HAMMONS APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2018
Last Update Date: 08/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14470 S LA GRANGE RD
ORLAND PARK IL
60462-2630
US

IV. Provider business mailing address

39 GRAYMOOR LN
OLYMPIA FIELDS IL
60461-1211
US

V. Phone/Fax

Practice location:
  • Phone: 708-349-2227
  • Fax: 708-349-5824
Mailing address:
  • Phone: 708-296-1665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberPENDING
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: