Provider Demographics
NPI:1093448474
Name:WISTERIA HEALTH SERVICES LTD
Entity Type:Organization
Organization Name:WISTERIA HEALTH SERVICES LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:309-221-1678
Mailing Address - Street 1:12860 E LYONS RD
Mailing Address - Street 2:
Mailing Address - City:LONDON MILLS
Mailing Address - State:IL
Mailing Address - Zip Code:61544-9393
Mailing Address - Country:US
Mailing Address - Phone:309-221-1678
Mailing Address - Fax:
Practice Address - Street 1:12860 E LYONS RD
Practice Address - Street 2:
Practice Address - City:LONDON MILLS
Practice Address - State:IL
Practice Address - Zip Code:61544-9393
Practice Address - Country:US
Practice Address - Phone:309-221-1678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-05
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty