Provider Demographics
NPI:1740075803
Name:WALLS, BOBBIE JO (APRN)
Entity type:Individual
Prefix:
First Name:BOBBIE
Middle Name:JO
Last Name:WALLS
Suffix:
Gender:
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4151 N 1500 EAST RD
Mailing Address - Street 2:
Mailing Address - City:RIDGE FARM
Mailing Address - State:IL
Mailing Address - Zip Code:61870-6099
Mailing Address - Country:US
Mailing Address - Phone:217-601-3143
Mailing Address - Fax:
Practice Address - Street 1:3653 N VERMILION ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-1118
Practice Address - Country:US
Practice Address - Phone:217-554-6827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-10
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.032170363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner