Provider Demographics
NPI:1023072527
Name:WALL, LINDA KAY (APN)
Entity type:Individual
Prefix:MS
First Name:LINDA
Middle Name:KAY
Last Name:WALL
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1196 LYNX LN
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-9389
Mailing Address - Country:US
Mailing Address - Phone:309-451-1628
Mailing Address - Fax:
Practice Address - Street 1:318 W WASHINGTON ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3875
Practice Address - Country:US
Practice Address - Phone:309-827-4014
Practice Address - Fax:309-828-6626
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-000339363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health