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General NPI Number Information
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NPI Number | 1407019946
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Entity Type | Individual
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Provider Name | SHARNA ANNISE WILTZ O.D.
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Gender | Female
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Dates
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Enumeration Date | 07/03/2008
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Last Update Date | 04/18/2018
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Provider Practice Location Address
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Address Line | 8309 N KNOXVILLE AVE STE 1
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City | PEORIA
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State | IL
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Zip | 61615-2171
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Country | US
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Telephone | 309-713-3664
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Fax |
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Provider Business Mailing Address
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Address Line | 8309 N KNOXVILLE AVE
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City | PEORIA
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State | IL
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Zip | 61615-2170
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Country | US
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Telephone | 309-693-9540
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 046009490
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License Number State | IL
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