Provider Demographics
NPI:1225124167
Name:WALLACE, LINDA (APN RN)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:APN RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1835 KINGHIGHWAY
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:62204
Mailing Address - Country:US
Mailing Address - Phone:618-482-7922
Mailing Address - Fax:618-482-7881
Practice Address - Street 1:1835 KINGHIGHWAY
Practice Address - Street 2:
Practice Address - City:WASHINGTON PARK
Practice Address - State:IL
Practice Address - Zip Code:62204
Practice Address - Country:US
Practice Address - Phone:618-482-7922
Practice Address - Fax:618-482-7881
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209003499174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209003499OtherLICENSE
IL209003499OtherLICENSE