Individual
MICHELLE LIDVALL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CRNA
Contact information
Practice address
221 NE GLEN OAK AVE, PEORIA, IL 61636-0001
(309) 672-5522
Mailing address
221 NE GLEN OAK AVE, PEORIA, IL 61636-0001
(309) 672-5522
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
041385084
IL
367500000X
Certified Registered Nurse Anesthetist
Primary
209.011831
IL
Other
Enumeration date
07/24/2014
Last updated
12/29/2014
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