Provider Demographics
NPI:1609222579
Name:WALLACE, DEANNA (NP)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:DEANNA
Other - Middle Name:
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1770 E LAKE SHORE DR STE 105
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-3800
Mailing Address - Country:US
Mailing Address - Phone:217-422-6100
Mailing Address - Fax:833-784-5326
Practice Address - Street 1:1770 E LAKE SHORE DR STE 105
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3800
Practice Address - Country:US
Practice Address - Phone:217-422-6100
Practice Address - Fax:833-784-5326
Is Sole Proprietor?:No
Enumeration Date:2016-05-10
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.014278207RC0000X
IL209014278363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01657319OtherRAILROAD
IL$$$$$$$$$001Medicaid
IL$$$$$$$$$001Medicaid