Provider Demographics
NPI:1275844797
Name:LACAILLADE, MEREDITH ROBERTS (APN - RN)
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:ROBERTS
Last Name:LACAILLADE
Suffix:
Gender:F
Credentials:APN - RN
Other - Prefix:
Other - First Name:MEREDITH
Other - Middle Name:ROBERTS
Other - Last Name:WYLDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:1849 GREEN BAY RD STE 220
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-3178
Mailing Address - Country:US
Mailing Address - Phone:847-433-7660
Mailing Address - Fax:847-433-7662
Practice Address - Street 1:1849 GREEN BAY RD STE 220
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-3178
Practice Address - Country:US
Practice Address - Phone:847-433-7660
Practice Address - Fax:847-433-7662
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009922363LF0000X
IL041405362163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL1765003Medicare PIN