Provider Demographics
NPI:1881112712
Name:LASAK, NICOLE (RN)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:LASAK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:841 MOCKING BIRD DR
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002-2726
Mailing Address - Country:US
Mailing Address - Phone:847-377-8278
Mailing Address - Fax:847-984-5676
Practice Address - Street 1:3002 GRAND AVE
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-2321
Practice Address - Country:US
Practice Address - Phone:847-377-8278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041404276163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator