Provider Demographics
NPI:1649984600
Name:LATTYAK, ELIZABETH ANN
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:ANN
Last Name:LATTYAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 WILLOW BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLOW SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:60480-1630
Mailing Address - Country:US
Mailing Address - Phone:708-369-3731
Mailing Address - Fax:
Practice Address - Street 1:4254 W 55TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-4642
Practice Address - Country:US
Practice Address - Phone:773-582-2660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.305291183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist