Wallace, Lizabeth

Wallace, Lizabeth is an individual health care provider with primary practice located at 420 Ne Glen Oak Ave , Peoria IL 61603-3105. She recently has only one registered license in Physician Assistants & Advanced Practice Nursing Providers / Nurse Practitioner, which is considered as her primary health care specialty. Wallace, Lizabeth can be contacted via phone (309) 655-2343.

Contact Information

Primary practice address
420 Ne Glen Oak Ave Peoria IL 61603-3105
Phone: (309) 655-2343
Fax: (309) 655-3948
Website:
Map and Directions

Health care specialties

SpecialtyCodeLicense #State
Physician Assistants & Advanced Practice Nursing Providers / Nurse Practitioner 363L00000X 0411285741-209004409 Illinois

Profile Details

NPI number 1417019084
LBN Legal business name Wallace, Lizabeth
Credentials
Entity Individual
Sole proprietor 1 No
Enumeration date Dec 13th, 2006
Last updated Apr 20th, 2009 - about 17 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1417019084 NPPES
Illinois Other 207594001 MEDICARE INDIVIDUAL ID/K35369 DEACTIVATED

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