MEDICARE: OLIVIA ANN WALDER APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	041454193	IL
2	363LF0000X	Family Nurse Practitioner	209027194	IL

General Provider Information

NPI Number	:	1407543838
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLIVIA ANN WALDER APRN

Provider Business Mailing Address
First Line	:	1120 N MELVIN ST
Second Line	:
City	:	GIBSON CITY
State	:	IL
Zip	:	60936-1477
Country	:	US
Telephone Number	:	217-784-4251
Fax Number	:

Provider Business Practice Location Address
First Line	:	912 W SEMINARY AVE
Second Line	:
City	:	ONARGA
State	:	IL
Zip	:	60955-1401
Country	:	US
Telephone Number	:	815-268-4840
Fax Number	:	815-268-4845

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/18/2023
Last Update Date	:	02/27/2024

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Directions to “ OLIVIA ANN WALDER APRN” Practice Location

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