Provider Demographics
NPI:1114061785
Name:VANDER WALL, LISA MARIE (RN, CF-M)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:VANDER WALL
Suffix:
Gender:F
Credentials:RN, CF-M
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 BELOT LN
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-9258
Mailing Address - Country:US
Mailing Address - Phone:815-485-5567
Mailing Address - Fax:
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-327-2058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL163WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WX0200XNursing Service ProvidersRegistered NurseOncology