=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861619280
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAUREN VACEK CNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2007
-----------------------------------------------------
Last Update Date | 07/08/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 324 ROOSEVELT RD TAKE CARE CLINIC
-----------------------------------------------------
City | GLEN ELLYN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60137-5647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-702-1679
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 278 MAPLEWOOD RD
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60546-1846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-442-1629
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 209-004474
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------