1659600039 NPI number — ELIZABETH JEAN WALLS ANP-BC

Table of content: ELIZABETH JEAN WALLS ANP-BC (NPI 1659600039)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659600039 NPI number — ELIZABETH JEAN WALLS ANP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLS
Provider First Name:
ELIZABETH
Provider Middle Name:
JEAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ANP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILSON
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
JEAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1659600039
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
252 CHAPMAN RD
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19702-5438
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-623-1929
Provider Business Mailing Address Fax Number:
302-366-1075

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BUILDING B-86
Provider Second Line Business Practice Location Address:
OMEGA DR
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19713-6004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-366-7665
Provider Business Practice Location Address Fax Number:
302-366-0734
Provider Enumeration Date:
12/15/2009

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: 363LA2200X , with the licence number:  LB0000230 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: LB0000230 . This is a "DE PROFESSIONAL LICENSE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 1659600039 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".




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