Healthcare Provider Details

I. General information

NPI: 1114896032
Provider Name (Legal Business Name): CHARLESETTA WALLACE APRN, CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2025
Last Update Date: 10/30/2025
Certification Date: 10/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 E OAKLAND AVE STE B
BLOOMINGTON IL
61701-5783
US

IV. Provider business mailing address

5100 W BRADFORD WOODS CIR APT T
PEORIA IL
61615-8978
US

V. Phone/Fax

Practice location:
  • Phone: 309-808-3068
  • Fax:
Mailing address:
  • Phone: 309-357-0768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number209033647
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: