Healthcare Provider Details

I. General information

NPI: 1679674857
Provider Name (Legal Business Name): VONDA K WALKER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 02/12/2021
Certification Date: 02/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 E BROADWAY ST
SPARTA IL
62286-1820
US

IV. Provider business mailing address

2 GOOD SAMARITAN WAY STE 205
MOUNT VERNON IL
62864-2476
US

V. Phone/Fax

Practice location:
  • Phone: 618-443-2177
  • Fax:
Mailing address:
  • Phone: 618-899-3869
  • Fax: 618-899-3558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209003936
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: