Provider Demographics
NPI:1730651829
Name:SHAVEZ, WALKER LEE (LPN)
Entity Type:Individual
Prefix:
First Name:WALKER
Middle Name:LEE
Last Name:SHAVEZ
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 GOOLSBY RD
Mailing Address - Street 2:
Mailing Address - City:ELDORADO
Mailing Address - State:IL
Mailing Address - Zip Code:62930-3647
Mailing Address - Country:US
Mailing Address - Phone:518-926-9352
Mailing Address - Fax:
Practice Address - Street 1:420 GOOLSBY RD
Practice Address - Street 2:
Practice Address - City:ELDORADO
Practice Address - State:IL
Practice Address - Zip Code:62930-3647
Practice Address - Country:US
Practice Address - Phone:618-926-9352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-30
Last Update Date:2018-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.126283164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse