MEDICARE: MRS. ANTOINETTE MARIE LEE APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	209.026385	IL

General Provider Information

NPI Number	:	1861101222
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ANTOINETTE MARIE LEE APRN

Provider Business Mailing Address
First Line	:	480 E ROOSEVELT RD STE 105
Second Line	:
City	:	WEST CHICAGO
State	:	IL
Zip	:	60185-3969
Country	:	US
Telephone Number	:	630-492-1965
Fax Number	:

Provider Business Practice Location Address
First Line	:	480 E ROOSEVELT RD STE 105
Second Line	:
City	:	WEST CHICAGO
State	:	IL
Zip	:	60185-3969
Country	:	US
Telephone Number	:	630-492-1965
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2022
Last Update Date	:	03/08/2024

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