Provider Demographics
NPI:1891551800
Name:PARK, LYDIA K (RN)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:K
Last Name:PARK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:LYDIA
Other - Middle Name:K
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:CAPTAIN JAMES
Mailing Address - Street 2:A LOVELL FHCC
Mailing Address - City:NORTH CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60064
Mailing Address - Country:US
Mailing Address - Phone:224-610-3886
Mailing Address - Fax:
Practice Address - Street 1:3715 MUNICIPAL DR
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-5483
Practice Address - Country:US
Practice Address - Phone:815-759-2306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-27
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILO41.507872163W00000X
IL041.507872163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse