Healthcare Provider Details

I. General information

NPI: 1609212257
Provider Name (Legal Business Name): KATHLEEN FRANCES WALLACH APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATHLEEN WALLACH SCHMIEGE

II. Dates (important events)

Enumeration Date: 05/21/2013
Last Update Date: 02/16/2024
Certification Date: 02/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 W 95TH ST
OAK LAWN IL
60453-2600
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1293
US

V. Phone/Fax

Practice location:
  • Phone: 708-684-5580
  • Fax: 708-684-4068
Mailing address:
  • Phone: 847-390-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1982958013
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number277.000970
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number277.000970
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: