Provider Demographics
NPI:1093702300
Name:COLLETT, LAURIE LYNN (OD)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:LYNN
Last Name:COLLETT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3406 VOLLMER RD
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1018
Mailing Address - Country:US
Mailing Address - Phone:708-748-6516
Mailing Address - Fax:708-748-6079
Practice Address - Street 1:3406 VOLLMER RD
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1018
Practice Address - Country:US
Practice Address - Phone:708-748-6516
Practice Address - Fax:708-748-6079
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-03
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008862152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U77799Medicare UPIN