Elizabeth Nicole Wallis, MD

Primary specialty

Pediatrics PhysicianTaxonomy code 208000000X

License

331615 Issued in LA

Practice address

200 W Monroe St Ste 302
Bloomington, IL 61701-3997

Phone

(309) 204-6766

NPI assigned

Apr 11, 2019

Sex

Female

Sole proprietor

No

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

Specialties & licenses 2

Addresses

Electronic endpoints 2

Medicare fee-for-service enrollment

Enrolled in LA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

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.

• South Louisiana Medical Associates

  • Surgery Physician
  • Houma, LA
  • NPI 1942301379
  Medicare reassignment

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

{
    "created_epoch": "1554940800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1785715200000",
    "number": "1821551334",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "200 W MONROE ST STE 302",
            "city": "BLOOMINGTON",
            "state": "IL",
            "postal_code": "617013997",
            "telephone_number": "309-204-6766"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "200 W MONROE ST STE 302",
            "city": "BLOOMINGTON",
            "state": "IL",
            "postal_code": "617013997",
            "telephone_number": "309-204-6766"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLIS",
        "first_name": "ELIZABETH",
        "middle_name": "NICOLE",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2019-04-11",
        "last_updated": "2026-08-03",
        "certification_date": "2026-08-03",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "IL",
            "license": "036.176418",
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "LA",
            "license": "331615",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "FHIR",
            "endpointTypeDescription": "FHIR URL",
            "endpoint": "https://epicproxy.et0830.epichosted.com/FHIRProxy/api/FHIR/DSTU2/",
            "affiliation": "N",
            "endpointDescription": "FMOLHS FHIR URL",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "FHIR API",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "C-CDA",
            "address_1": "1937 S Burnside Ave",
            "city": "Gonzales",
            "state": "LA",
            "country_code": "US",
            "postal_code": "707374632",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "ewallis552569@direct.casso.us.com",
            "affiliation": "N",
            "endpointDescription": "FMOLHS-Epic",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "ewallis552569@direct.casso.us.com",
            "address_1": "1937 S Burnside Ave",
            "city": "Gonzales",
            "state": "LA",
            "country_code": "US",
            "postal_code": "707374632",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Alicia S Wallace
• Charlesetta Wallace, APRN, CNM
• Lindsey Wallace
• Megan M Wallace, AU.D.
• Nona K Waller
• Walmart Inc.
• Susan Sarita Walsh
• Cynthia J Walter, LCPC
• McKinsey Walters
• Rachael Z Wambui

• Pediatrics Physician in Bloomington, IL
• Providers in Bloomington, IL by specialty
• Pediatrics Physician in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 3, 2026; 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.