Provider Demographics
NPI:1407019946
Name:WILTZ, SHARNA ANNISE (OD)
Entity Type:Individual
Prefix:DR
First Name:SHARNA
Middle Name:ANNISE
Last Name:WILTZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8309 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2170
Mailing Address - Country:US
Mailing Address - Phone:309-693-9540
Mailing Address - Fax:
Practice Address - Street 1:8309 N KNOXVILLE AVE STE 1
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-2171
Practice Address - Country:US
Practice Address - Phone:309-713-3664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009490152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist