Healthcare Provider Details

I. General information

NPI: 1740736719
Provider Name (Legal Business Name): MEREDITH WALTER APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2016
Last Update Date: 04/03/2020
Certification Date: 04/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4979 INDIANA AVE
LISLE IL
60532-3847
US

IV. Provider business mailing address

4979 INDIANA AVE STE 312
LISLE IL
60532-3850
US

V. Phone/Fax

Practice location:
  • Phone: 312-337-4150
  • Fax: 312-337-4311
Mailing address:
  • Phone: 312-337-4150
  • Fax: 312-337-4311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0000000000
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: