Basic Information
Provider Information | |||||||||
NPI: | 1184666836 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WAHLMAN | ||||||||
FirstName: | JANELLE | ||||||||
MiddleName: | A. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CNM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KOMOROWSKI | ||||||||
OtherFirstName: | JANELLE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CNM | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1627 E 18TH ST | ||||||||
Address2: |   | ||||||||
City: | LOVELAND | ||||||||
State: | CO | ||||||||
PostalCode: | 805384209 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9706630135 | ||||||||
FaxNumber: | 9704611422 | ||||||||
Practice Location | |||||||||
Address1: | 1647 E 18TH ST | ||||||||
Address2: |   | ||||||||
City: | LOVELAND | ||||||||
State: | CO | ||||||||
PostalCode: | 805384209 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9706639523 | ||||||||
FaxNumber: | 9706220349 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/10/2006 | ||||||||
LastUpdateDate: | 02/20/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 86963 | CO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |   |
ID Information
ID | Type | State | Issuer | Description | 72277556 | 05 | CO |   | MEDICAID |