Provider Demographics
NPI:1659081859
Name:LATTERY, LAUREN JAYNE (OD, MS)
Entity Type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:JAYNE
Last Name:LATTERY
Suffix:
Gender:F
Credentials:OD, MS
Other - Prefix:MS
Other - First Name:LAUREN
Other - Middle Name:JAYNE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4122 BITTERNUT LN APT 301
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-9351
Mailing Address - Country:US
Mailing Address - Phone:952-381-4167
Mailing Address - Fax:
Practice Address - Street 1:3350 ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:GREAT LAKES
Practice Address - State:IL
Practice Address - Zip Code:60088
Practice Address - Country:US
Practice Address - Phone:847-688-5568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-29
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10562152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10562TOtherTRICARE