Provider Demographics
NPI:1679674857
Name:WALKER, VONDA K (CRNA)
Entity type:Individual
Prefix:
First Name:VONDA
Middle Name:K
Last Name:WALKER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 GOOD SAMARITAN WAY STE 205
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2476
Mailing Address - Country:US
Mailing Address - Phone:618-899-3869
Mailing Address - Fax:618-899-3558
Practice Address - Street 1:818 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:IL
Practice Address - Zip Code:62286-1820
Practice Address - Country:US
Practice Address - Phone:618-443-2177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209003936367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK16590Medicare ID - Type Unspecified