Provider Demographics
NPI:1164690830
Name:OLIVARES, LENNY (CRNA)
Entity Type:Individual
Prefix:
First Name:LENNY
Middle Name:
Last Name:OLIVARES
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14518 ABBOTT ROAD EAST
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-9227
Mailing Address - Country:US
Mailing Address - Phone:312-371-8129
Mailing Address - Fax:
Practice Address - Street 1:9301 CONNECTICUT DRIVE
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-7486
Practice Address - Country:US
Practice Address - Phone:219-756-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-15
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL077125367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered