Healthcare Provider Details

I. General information

NPI: 1285544304
Provider Name (Legal Business Name): MIDWEST EXPRESS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 E 107TH AVE
CROWN POINT IN
46307-6517
US

IV. Provider business mailing address

129 E 107TH AVE
CROWN POINT IN
46307-6517
US

V. Phone/Fax

Practice location:
  • Phone: 219-662-4134
  • Fax:
Mailing address:
  • Phone: 219-662-4134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: EMMA A WAHLSTROM
Title or Position: NURSE PRACTITIONER
Credential: NP
Phone: 708-822-7214