Healthcare Provider Details

I. General information

NPI: 1225035504
Provider Name (Legal Business Name): KATHLEEN WALLACE APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 12/13/2022
Certification Date: 12/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 W 86TH AVE
MERRILLVILLE IN
46410-7086
US

IV. Provider business mailing address

120 W 22ND ST STE 200
OAK BROOK IL
60523-1563
US

V. Phone/Fax

Practice location:
  • Phone: 219-791-1555
  • Fax: 219-791-1560
Mailing address:
  • Phone: 630-573-5000
  • Fax: 630-491-5472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71000826A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: