Lizabeth Wallace

Primary specialty

Nurse PractitionerTaxonomy code 363L00000X

License

0411285741-209004409 Issued in IL

Practice address

420 NE Glen Oak Ave
Peoria, IL 61603-3105

Phone

(309) 655-2343

Fax

(309) 655-3948

NPI assigned

Dec 13, 2006

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in IL

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Osf Multi-Specialty Group

  • Internal Medicine Physician
  • Peoria, IL
  • NPI 1922445527
  Medicare reassignment NPD
• Central PA Pharmacy LLC.

  • Community/Retail Pharmacy
  • Patton, PA
  • NPI 1578541413
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1165968000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1240185600000",
    "number": "1417019084",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "420 NE GLEN OAK AVE",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616033105",
            "telephone_number": "309-655-2343",
            "fax_number": "309-655-3948"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "420 NE GLEN OAK AVE",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616033105",
            "telephone_number": "309-655-2343",
            "fax_number": "309-655-3948"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "LIZABETH",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-12-13",
        "last_updated": "2009-04-20",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "IL",
            "license": "0411285741-209004409",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE INDIVIDUAL ID/K35369 DEACTIVATED",
            "identifier": "207594001",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Kiara Walker
• Margaret Louise Walker, B.S.
• Cory Edward Wallace
• Donald R. Wallace, M.D.
• Jami Michelle Wallace, APRN
• Allison Carole Wallenfang, MD
• Brandy Wallin
• Bethany Walls
• Emily Walls
• Walmart Inc.

• Nurse Practitioner in Peoria, IL
• Providers in Peoria, IL by specialty
• Nurse Practitioner in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 20, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.