Provider Demographics
NPI:1013661859
Name:LASISI, CHIBUZO
Entity type:Individual
Prefix:
First Name:CHIBUZO
Middle Name:
Last Name:LASISI
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4749 LINCOLN MALL DR STE 202H
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-3826
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5320 159TH ST STE 303B
Practice Address - Street 2:
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452-4705
Practice Address - Country:US
Practice Address - Phone:815-435-4055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-10
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.024779363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily