Healthcare Provider Details

I. General information

NPI: 1023072527
Provider Name (Legal Business Name): LINDA KAY WALL A.P.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 12/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 W WASHINGTON ST 3RD FLOOR
BLOOMINGTON IL
61701-3875
US

IV. Provider business mailing address

1196 LYNX LN
NORMAL IL
61761-9389
US

V. Phone/Fax

Practice location:
  • Phone: 309-827-4014
  • Fax: 309-828-6626
Mailing address:
  • Phone: 309-451-1628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number209-000339
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: