Individual
KELSEY A WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CRNA
Contact information
Practice address
701 N 1ST ST, SPRINGFIELD, IL 62781-0001
(217) 788-3000
Mailing address
PO BOX 3428, SPRINGFIELD, IL 62708-3428
(217) 588-2624
(217) 757-2021
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
209019523
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
041-420825
RN LICENSE
IL
01
—
209019523
CRNA LICENSE
IL
Enumeration date
06/13/2019
Last updated
06/17/2019
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