Healthcare Provider Details

I. General information

NPI: 1669983789
Provider Name (Legal Business Name): ELIZABETH LAUREN STUART NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH L WALL NP-C

II. Dates (important events)

Enumeration Date: 10/16/2017
Last Update Date: 12/09/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 N RUTLEDGE ST STE 1100
SPRINGFIELD IL
62702-4968
US

IV. Provider business mailing address

PO BOX 19636
SPRINGFIELD IL
62794-9636
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax: 217-788-5504
Mailing address:
  • Phone: 217-545-8000
  • Fax: 217-788-5504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.402814
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.016146
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: