Healthcare Provider Details

I. General information

NPI: 1487110219
Provider Name (Legal Business Name): ANN WALSH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2019
Last Update Date: 01/28/2022
Certification Date: 01/28/2022
Deactivation Date: 07/28/2021
Reactivation Date: 08/11/2021

III. Provider practice location address

720 FLORSHEIM DR
LIBERTYVILLE IL
60048-3757
US

IV. Provider business mailing address

900 RAND RD STE 300
DES PLAINES IL
60016-2359
US

V. Phone/Fax

Practice location:
  • Phone: 847-247-4000
  • Fax: 847-234-2090
Mailing address:
  • Phone: 847-324-3976
  • Fax: 847-929-1154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-008629
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT019-74946
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: