Healthcare Provider Details

I. General information

NPI: 1740200732
Provider Name (Legal Business Name): ELIZABETH A. WALL R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5847 S. MARYLAND AVE MC 4080
CHICAGO IL
60637
US

IV. Provider business mailing address

911 SHERIDAN RD
EVANSTON IL
60202-5432
US

V. Phone/Fax

Practice location:
  • Phone: 773-834-2876
  • Fax: 773-702-6972
Mailing address:
  • Phone: 773-834-2876
  • Fax: 773-702-6972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: