Healthcare Provider Details

I. General information

NPI: 1629471297
Provider Name (Legal Business Name): JENNIFER L WALSTON AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER L RAINES

II. Dates (important events)

Enumeration Date: 09/26/2014
Last Update Date: 06/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 N RUTLEDGE ST SUITE 1700
SPRINGFIELD IL
62702-4968
US

IV. Provider business mailing address

751 N RUTLEDGE ST PO BOX 19636
SPRINGFIELD IL
62702-4968
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax: 217-545-7063
Mailing address:
  • Phone: 217-545-8000
  • Fax: 217-545-7063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number209011920
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: