Provider Demographics
NPI:1922315126
Name:BENNETT, LISA A (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:BENNETT
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:KEYS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:4012 S INDIANA AVE
Mailing Address - Street 2:UNIT 1N
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653
Mailing Address - Country:US
Mailing Address - Phone:773-880-4757
Mailing Address - Fax:773-880-3208
Practice Address - Street 1:225 E CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:312-227-6090
Practice Address - Fax:312-227-9403
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-09
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.008268363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics