Healthcare Provider Details

I. General information

NPI: 1104216944
Provider Name (Legal Business Name): WALLACE BARRETT JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2015
Last Update Date: 11/17/2022
Certification Date: 11/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 FRANCISCAN DR
LITCHFIELD IL
62056-1778
US

IV. Provider business mailing address

PO BOX 10484
BIRMINGHAM AL
35202-0484
US

V. Phone/Fax

Practice location:
  • Phone: 217-324-8389
  • Fax:
Mailing address:
  • Phone: 800-339-5844
  • Fax: 866-759-5426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number041.406110
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209012598
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: