1720084486 NPI number — MISS MARY JEAN WALLIN CERTIFIED NURSE MIDW

Table of content: MISS MARY JEAN WALLIN CERTIFIED NURSE MIDW (NPI 1720084486)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720084486 NPI number — MISS MARY JEAN WALLIN CERTIFIED NURSE MIDW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLIN
Provider First Name:
MARY
Provider Middle Name:
JEAN
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
CERTIFIED NURSE MIDW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STUTSON
Provider Other First Name:
MARY
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CNM
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1720084486
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5074
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57117-5074
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-328-6585
Provider Business Mailing Address Fax Number:
605-328-6512

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 W 22ND ST STE 301
Provider Second Line Business Practice Location Address:
SANFORD HEALTH MATERNAL FETAL MEDICINE CLINIC
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57105-1503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-328-7700
Provider Business Practice Location Address Fax Number:
605-328-7775
Provider Enumeration Date:
06/27/2005

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: 367A00000X , with the licence number:  0023 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 176B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6540104 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".