Provider Demographics
NPI:1578837746
Name:WAHLSTROM, NANCY ALICE (CSFA/CST)
Entity Type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:ALICE
Last Name:WAHLSTROM
Suffix:
Gender:F
Credentials:CSFA/CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2730 BRASSIE AVE
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-1822
Mailing Address - Country:US
Mailing Address - Phone:708-363-1317
Mailing Address - Fax:
Practice Address - Street 1:2730 BRASSIE AVE
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-1822
Practice Address - Country:US
Practice Address - Phone:708-363-1317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-05
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant