Provider Demographics
NPI:1609222579
Name:WALLACE, DEANNA (NP)
Entity type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:DEANNA
Other - Middle Name:
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:611 W PARK
Mailing Address - Street 2:FAPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61802
Mailing Address - Country:US
Mailing Address - Phone:217-902-6954
Mailing Address - Fax:217-902-7711
Practice Address - Street 1:611 W PARK
Practice Address - Street 2:FAPC
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61802
Practice Address - Country:US
Practice Address - Phone:217-902-6954
Practice Address - Fax:217-902-7711
Is Sole Proprietor?:No
Enumeration Date:2016-05-10
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.014278207RC0000X
IL209014278363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$Medicaid
ILP01657319OtherRAILROAD
IL$$$$$$$$$001Medicaid