1265517197 NPI number — JENNIE L. WALLS FNP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265517197 NPI number — JENNIE L. WALLS FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLS
Provider First Name:
JENNIE
Provider Middle Name:
L.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265517197
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 70403
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSON CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37614-1703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-439-4078
Provider Business Mailing Address Fax Number:
423-439-4060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
DAVID CROCKETT HIGH SCHOOL HEALTH CLINIC
Provider Second Line Business Practice Location Address:
684 OLD STATE ROUTE 34
Provider Business Practice Location Address City Name:
JONESBOROUGH
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37659
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-753-0057
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/26/2006

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: 363LF0000X , with the licence number:  APN5169 , 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: APN5169 . This is a "APN LICENSE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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