Provider Demographics
NPI:1194412072
Name:WEATHERSBY, LENITA
Entity type:Individual
Prefix:
First Name:LENITA
Middle Name:
Last Name:WEATHERSBY
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 1:2100 YORK ST APT 1F
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-2568
Mailing Address - Country:US
Mailing Address - Phone:773-953-3749
Mailing Address - Fax:
Practice Address - Street 1:6821 S HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-1833
Practice Address - Country:US
Practice Address - Phone:773-651-3629
Practice Address - Fax:773-322-1599
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-20
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041511278163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice