Healthcare Provider Details

I. General information

NPI: 1326420530
Provider Name (Legal Business Name): NATHASA WALLACE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2015
Last Update Date: 07/16/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 W 155TH ST
HARVEY IL
60426-3556
US

IV. Provider business mailing address

31 W 155TH ST
HARVEY IL
60426-3556
US

V. Phone/Fax

Practice location:
  • Phone: 708-596-5177
  • Fax: 708-596-5518
Mailing address:
  • Phone: 708-596-5177
  • Fax: 708-596-5518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.012383
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: