Basic Information
| Provider Information | |||||||||
| NPI: | 1558960674 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLS | ||||||||
| FirstName: | ALICIA | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN, FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WALLS-HOLLER | ||||||||
| OtherFirstName: | ALICIA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3170 KETTERING BLVD BLDG B2 | ||||||||
| Address2: | |||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379913188 | ||||||||
| FaxNumber: | 9372239811 | ||||||||
| Practice Location | |||||||||
| Address1: | 98 MOSIER PKWY | ||||||||
| Address2: | |||||||||
| City: | BROOKVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453091750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9378334103 | ||||||||
| FaxNumber: | 9378333147 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2020 | ||||||||
| LastUpdateDate: | 03/30/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APRN.CNP.0027836 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | APRN.CNP.0027836 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0442294 | 05 | OH | MEDICAID |