Healthcare Provider Details

I. General information

NPI: 1003510009
Provider Name (Legal Business Name): DANIELLE ALYSSA WALES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 BALLARD RD
PARK RIDGE IL
60068-1005
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1293
US

V. Phone/Fax

Practice location:
  • Phone: 847-318-6020
  • Fax:
Mailing address:
  • Phone: 847-390-5900
  • Fax: 847-390-4757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036181134
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: