Provider Demographics
NPI:1972584423
Name:O'MALLEY, TERRI LYNNE (JD, MD)
Entity type:Individual
Prefix:DR
First Name:TERRI
Middle Name:LYNNE
Last Name:O'MALLEY
Suffix:
Gender:F
Credentials:JD, MD
Other - Prefix:
Other - First Name:TERRI
Other - Middle Name:LYNNE
Other - Last Name:VAN ZANDT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5615 IRISH LANE
Mailing Address - Street 2:
Mailing Address - City:HARVARD
Mailing Address - State:IL
Mailing Address - Zip Code:60033
Mailing Address - Country:US
Mailing Address - Phone:815-245-1502
Mailing Address - Fax:815-943-2848
Practice Address - Street 1:5615 IRISH LANE
Practice Address - Street 2:
Practice Address - City:HARVARD
Practice Address - State:IL
Practice Address - Zip Code:60033
Practice Address - Country:US
Practice Address - Phone:815-245-1502
Practice Address - Fax:815-943-2848
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036 095762208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036 095762Medicaid