Individual
LIZABETH WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
420 NE GLEN OAK AVE, PEORIA, IL 61603-3105
(309) 655-2343
(309) 655-3948
Mailing address
420 NE GLEN OAK AVE, PEORIA, IL 61603-3105
(309) 655-2343
(309) 655-3948
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
0411285741-209004409
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
207594001
MEDICARE INDIVIDUAL ID/K35369 DEACTIVATED
IL
Enumeration date
12/13/2006
Last updated
04/20/2009
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