Provider Demographics
NPI:1225390479
Name:SAMUELSON, LANAY L (ANP)
Entity Type:Individual
Prefix:
First Name:LANAY
Middle Name:L
Last Name:SAMUELSON
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 N ELM ST
Mailing Address - Street 2:STE 115
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-3634
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:911 N ELM ST
Practice Address - Street 2:STE 115
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3634
Practice Address - Country:US
Practice Address - Phone:630-861-6655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-13
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL00000000363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2011016785OtherNATIONAL CERTIFICATION - ANCC