Provider Demographics
NPI:1922827542
Name:LAFAYETTE MED, PLLC
Entity type:Organization
Organization Name:LAFAYETTE MED, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:K-SHAYLA
Authorized Official - Middle Name:
Authorized Official - Last Name:LAFAYETTE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, FNP - BC, FPA
Authorized Official - Phone:815-908-9685
Mailing Address - Street 1:1563 SUN RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-9644
Mailing Address - Country:US
Mailing Address - Phone:815-908-9685
Mailing Address - Fax:
Practice Address - Street 1:1563 SUN RIDGE DR
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-9644
Practice Address - Country:US
Practice Address - Phone:815-908-9685
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-09
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care