Provider Demographics
NPI:1588608095
Name:WALKER, JUSTINE ANTOINETTE (FNP)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:ANTOINETTE
Last Name:WALKER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17700 DEVON DR
Mailing Address - Street 2:
Mailing Address - City:COUNTRY CLUB HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60478-4845
Mailing Address - Country:US
Mailing Address - Phone:773-294-4183
Mailing Address - Fax:
Practice Address - Street 1:650 PHOENIX CENTER DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:IL
Practice Address - Zip Code:60426-2408
Practice Address - Country:US
Practice Address - Phone:708-225-9900
Practice Address - Fax:708-225-9997
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-000804363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK47295Medicare PIN
ILK47294Medicare PIN