Healthcare Provider Details

I. General information

NPI: 1104568948
Provider Name (Legal Business Name): LAKIMIYION WALLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2022
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15737 TERRACE DR APT 1BL
OAK FOREST IL
60452-5190
US

IV. Provider business mailing address

15737 TERRACE DR APT 1BL
OAK FOREST IL
60452-5190
US

V. Phone/Fax

Practice location:
  • Phone: 773-308-4653
  • Fax:
Mailing address:
  • Phone: 773-308-4653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number043112709
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: