Provider Demographics
NPI:1588990931
Name:LIN, LISA SUKLAM (CNP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:SUKLAM
Last Name:LIN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:CHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1325 COMMUNITY MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2659
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1325 COMMUNITY MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2659
Practice Address - Country:US
Practice Address - Phone:708-245-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-20
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209013126363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily