Provider Demographics
NPI:1093083966
Name:LINCOLN-STALLWORTH, RENETTA DENISE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:RENETTA
Middle Name:DENISE
Last Name:LINCOLN-STALLWORTH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11110 S HOMEWOOD AVE
Mailing Address - Street 2:#A1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-4233
Mailing Address - Country:US
Mailing Address - Phone:773-425-5951
Mailing Address - Fax:
Practice Address - Street 1:11110 S HOMEWOOD AVE
Practice Address - Street 2:#A1
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-4233
Practice Address - Country:US
Practice Address - Phone:773-425-5951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043084625164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse