Provider Demographics
NPI:1013641158
Name:WALLACE, ERIN MAUREEN
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:MAUREEN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19W286 GOVERNORS TRL
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1030
Mailing Address - Country:US
Mailing Address - Phone:516-567-5966
Mailing Address - Fax:
Practice Address - Street 1:1731 S NAPERVILLE ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60189
Practice Address - Country:US
Practice Address - Phone:630-653-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program