=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891218087
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUTRICIA BANKS LPN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2017
-----------------------------------------------------
Last Update Date | 07/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4131 WEHRMAN AVE
-----------------------------------------------------
City | SCHILLER PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60176-1844
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-678-0380
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2105 S 7TH AVE
-----------------------------------------------------
City | MAYWOOD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60153-3222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 043073978
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------