Provider Demographics
NPI:1104216944
Name:BARRETT, WALLACE JR (CRNA)
Entity Type:Individual
Prefix:MR
First Name:WALLACE
Middle Name:
Last Name:BARRETT
Suffix:JR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10484
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35202-0484
Mailing Address - Country:US
Mailing Address - Phone:800-339-5844
Mailing Address - Fax:866-759-5426
Practice Address - Street 1:1215 FRANCISCAN DR
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:IL
Practice Address - Zip Code:62056-1778
Practice Address - Country:US
Practice Address - Phone:217-324-8389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-02
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.406110367500000X
IL209012598367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered