=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285544304
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDWEST EXPRESS CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2026
-----------------------------------------------------
Last Update Date | 09/10/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 129 E 107TH AVE
-----------------------------------------------------
City | CROWN POINT
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46307-6517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-662-4134
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 129 E 107TH AVE
-----------------------------------------------------
City | CROWN POINT
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46307-6517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-662-4134
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITIONER
-----------------------------------------------------
Name | EMMA A WAHLSTROM
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 708-822-7214
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------