Basic Information
| Provider Information | |||||||||
| NPI: | 1396014650 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | RENEE | ||||||||
| MiddleName: | |||||||||
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| Credential: | APN | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | LASKOWSKI | ||||||||
| OtherFirstName: | RENEE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 251 EAST HURON | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129262808 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1653 W CONGRESS PKWY | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606123833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129424252 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2011 | ||||||||
| LastUpdateDate: | 11/27/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SA2100X | 209009104 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Acute Care | 363LA2100X | 209009104 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 1396014650 | 05 | IL | MEDICAID |