Provider Demographics
NPI:1609212257
Name:WALLACH, KATHLEEN FRANCES (APN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:FRANCES
Last Name:WALLACH
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:WALLACH
Other - Last Name:SCHMIEGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1293
Mailing Address - Country:US
Mailing Address - Phone:847-390-5900
Mailing Address - Fax:
Practice Address - Street 1:4440 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2600
Practice Address - Country:US
Practice Address - Phone:708-684-5580
Practice Address - Fax:708-684-4068
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-21
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1982958013208000000X
IL277.000970363L00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty