Provider Demographics
NPI:1225035504
Name:WALLACE, KATHLEEN (APN)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W 22ND ST STE 200
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1563
Mailing Address - Country:US
Mailing Address - Phone:630-573-5000
Mailing Address - Fax:630-491-5472
Practice Address - Street 1:90 W 86TH AVE
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-7086
Practice Address - Country:US
Practice Address - Phone:219-791-1555
Practice Address - Fax:219-791-1560
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000826A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000331131OtherANTHEM BCBS NUMBER
IN100082060Medicaid
IN200280140BMedicaid
IN500012853OtherRR MEDICARE