Provider Demographics
NPI:1912225202
Name:WOJCIECHOWSKI, LILLA
Entity Type:Individual
Prefix:
First Name:LILLA
Middle Name:
Last Name:WOJCIECHOWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LILLA
Other - Middle Name:
Other - Last Name:SZUSTEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP-BC
Mailing Address - Street 1:9125 S PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-1441
Mailing Address - Country:US
Mailing Address - Phone:708-422-7715
Mailing Address - Fax:708-422-7816
Practice Address - Street 1:9125 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-1441
Practice Address - Country:US
Practice Address - Phone:708-422-7715
Practice Address - Fax:708-422-7816
Is Sole Proprietor?:No
Enumeration Date:2010-05-11
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.008025363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid