Healthcare Provider Details

I. General information

NPI: 1821551334
Provider Name (Legal Business Name): ELIZABETH NICOLE WALLIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2019
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W MONROE ST STE 302
BLOOMINGTON IL
61701-3997
US

IV. Provider business mailing address

200 W MONROE ST STE 302
BLOOMINGTON IL
61701-3997
US

V. Phone/Fax

Practice location:
  • Phone: 309-204-6766
  • Fax:
Mailing address:
  • Phone: 309-204-6766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.176418
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number331615
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: