Provider Demographics
NPI:1982818084
Name:REICHARDT, LISA (MS, APRN, CWOCN)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:REICHARDT
Suffix:
Gender:F
Credentials:MS, APRN, CWOCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 S PARK RD
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2128
Mailing Address - Country:US
Mailing Address - Phone:708-579-3191
Mailing Address - Fax:
Practice Address - Street 1:5000 S 5TH AVE
Practice Address - Street 2:
Practice Address - City:HINES
Practice Address - State:IL
Practice Address - Zip Code:60141-3030
Practice Address - Country:US
Practice Address - Phone:708-202-8387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-005646364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist