Provider Demographics
NPI:1417019084
Name:WALLACE, LIZABETH
Entity Type:Individual
Prefix:
First Name:LIZABETH
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 NE GLEN OAK AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3105
Mailing Address - Country:US
Mailing Address - Phone:309-655-2343
Mailing Address - Fax:309-655-3948
Practice Address - Street 1:420 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3105
Practice Address - Country:US
Practice Address - Phone:309-655-2343
Practice Address - Fax:309-655-3948
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0411285741-209004409363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL207594001OtherMEDICARE INDIVIDUAL ID/K35369 DEACTIVATED
ILK35369Medicare ID - Type UnspecifiedINDIVIDUAL #
IL207594001OtherMEDICARE INDIVIDUAL ID/K35369 DEACTIVATED
IL207594Medicare ID - Type UnspecifiedGROUP #