Provider Demographics
NPI:1215479621
Name:ABU-SAMRA, LISA (CNM)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:ABU-SAMRA
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1890 SILVER CROSS BLVD STE 315
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-9605
Mailing Address - Country:US
Mailing Address - Phone:815-300-7764
Mailing Address - Fax:
Practice Address - Street 1:17047 LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60487-7227
Practice Address - Country:US
Practice Address - Phone:815-300-7764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-16
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015160367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife