Provider Demographics
NPI:1497831549
Name:MATHEW, LIZAMMA (NP)
Entity Type:Individual
Prefix:
First Name:LIZAMMA
Middle Name:
Last Name:MATHEW
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1685 HOLLY AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-5021
Mailing Address - Country:US
Mailing Address - Phone:312-864-3400
Mailing Address - Fax:312-864-9765
Practice Address - Street 1:1901-WEST-HARRISON STREET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612
Practice Address - Country:US
Practice Address - Phone:312-864-6000
Practice Address - Fax:312-864-9765
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-004591363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health