1043252190 NPI number — MRS. JILL SUZANNE WALL P.A.

Table of content: MRS. JILL SUZANNE WALL P.A. (NPI 1043252190)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043252190 NPI number — MRS. JILL SUZANNE WALL P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALL
Provider First Name:
JILL
Provider Middle Name:
SUZANNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DAY
Provider Other First Name:
JILL
Provider Other Middle Name:
SUZANNE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1043252190
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
917 SPRINGTIME TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEYMOUR
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37865-3256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-789-1595
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
742 MIDDLECREEK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEVIERVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37862-5047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-446-8835
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/12/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  1193 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00285556 . This is a "RRGA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4095095 . This is a "BLUE CROSS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3663358 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".