Basic Information
| Provider Information | |||||||||
| NPI: | 1225124167 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | LINDA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APN RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1835 KINGHIGHWAY | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184827922 | ||||||||
| FaxNumber: | 6184827881 | ||||||||
| Practice Location | |||||||||
| Address1: | 1835 KINGHIGHWAY | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184827922 | ||||||||
| FaxNumber: | 6184827881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 09/12/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 209003499 | IL | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 209003499 | 01 | IL | LICENSE | OTHER |