Provider Demographics
NPI:1346600806
Name:O'NEAL-REESE, LAVETTE
Entity Type:Individual
Prefix:
First Name:LAVETTE
Middle Name:
Last Name:O'NEAL-REESE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14241 S STEWART AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60827-2339
Mailing Address - Country:US
Mailing Address - Phone:708-699-4487
Mailing Address - Fax:
Practice Address - Street 1:14241 S STEWART AVE
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:IL
Practice Address - Zip Code:60827-2339
Practice Address - Country:US
Practice Address - Phone:708-699-4487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-26
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILO54653779948172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver