Provider Demographics
NPI:1134888480
Name:LEWIS, SHALANDA
Entity type:Individual
Prefix:
First Name:SHALANDA
Middle Name:
Last Name:LEWIS
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 1:16029 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-1766
Mailing Address - Country:US
Mailing Address - Phone:312-479-1530
Mailing Address - Fax:
Practice Address - Street 1:12863 S NORMAL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-7436
Practice Address - Country:US
Practice Address - Phone:312-479-1530
Practice Address - Fax:312-479-1530
Is Sole Proprietor?:No
Enumeration Date:2021-12-14
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14D2245600247ZC0005X
IN25-018717376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL873956300OtherLABORATORY
IL873956300OtherLAB
IL873956300OtherLABORATORY