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Individual

LAWANDA WALLACE

Active
Sole proprietor
Yes

Provider details

NPI number
Gender
F

Contact information

Practice address
11559 S OAKLEY AVE, CHICAGO, IL 60643-4721
(773) 391-6689
Mailing address
11559 S OAKLEY AVE, CHICAGO, IL 60643-4721
(773) 391-6689

Taxonomy

Speciality
Code
Description
License number
State
347C00000X
Private Vehicle
Primary
W42053371706
IL

Other

Enumeration date
01/26/2016
Last updated
01/26/2016
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