Provider Demographics
NPI:1700232733
Name:HARRIETT, LAUREN (DO)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:HARRIETT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2606
Mailing Address - Country:US
Mailing Address - Phone:708-383-0113
Mailing Address - Fax:773-836-7381
Practice Address - Street 1:115 N PARKSIDE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60644-3040
Practice Address - Country:US
Practice Address - Phone:773-295-3060
Practice Address - Fax:773-295-3061
Is Sole Proprietor?:No
Enumeration Date:2016-05-09
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILH63052587921390200000X
IL036148337207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program