Provider Demographics
NPI:1326936865
Name:WILSON, LISA CHARIVUKALAYIL
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:CHARIVUKALAYIL
Last Name:WILSON
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 1:7741 W CATALPA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60656-1638
Mailing Address - Country:US
Mailing Address - Phone:773-808-9330
Mailing Address - Fax:
Practice Address - Street 1:7741 W CATALPA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60656-1638
Practice Address - Country:US
Practice Address - Phone:773-808-9330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-24
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209032604363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner