1902087372 NPI number — MRS. PAMELA ANN WALLIS CCC/SLP

Table of content: MRS. PAMELA ANN WALLIS CCC/SLP (NPI 1902087372)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902087372 NPI number — MRS. PAMELA ANN WALLIS CCC/SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLIS
Provider First Name:
PAMELA
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CCC/SLP
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:
1902087372
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/14/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15124 CEDAR HEIGHTS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72118-1290
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-851-4027
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
708 E DIXON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72206-4114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-490-5837
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/14/2007

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: 235Z00000X , with the licence number:  1490 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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