Basic Information
| Provider Information | |||||||||
| NPI: | 1053305128 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOTTS | ||||||||
| FirstName: | WENDY | ||||||||
| MiddleName: | JANE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOFFATT | ||||||||
| OtherFirstName: | WENDY | ||||||||
| OtherMiddleName: | JANE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 15 TOWER CT | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GURNEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600313336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472441375 | ||||||||
| FaxNumber: | 8472441002 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 TOWER CT | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GURNEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600313336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472441375 | ||||||||
| FaxNumber: | 8472441002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2005 | ||||||||
| LastUpdateDate: | 11/30/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 036085957 | IL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 036035957 | 05 | IL | MEDICAID |