1376664284 NPI number — MS. JUSTINE ALEXANDRA WALL M.S.

Table of content: MS. JUSTINE ALEXANDRA WALL M.S. (NPI 1376664284)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376664284 NPI number — MS. JUSTINE ALEXANDRA WALL M.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALL
Provider First Name:
JUSTINE
Provider Middle Name:
ALEXANDRA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
M.S.
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:
1376664284
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/16/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1709 JACKSON STREET
Provider Second Line Business Mailing Address:
OMAHA
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-599-2551
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1709 JACKSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68102-2513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-599-2551
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/02/2007

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: 101YM0800X , with the licence number:  3474 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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