Healthcare Provider Details

I. General information

NPI: 1346694841
Provider Name (Legal Business Name): TRACI WALK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2016
Last Update Date: 04/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20379 E 1100TH AVE
DIETERICH IL
62424-2114
US

IV. Provider business mailing address

20379 E 1100TH AVE
DIETERICH IL
62424-2114
US

V. Phone/Fax

Practice location:
  • Phone: 217-663-2876
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160006981
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: