Basic Information
| Provider Information | |||||||||
| NPI: | 1679508253 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLING | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MSN FNPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3349 US 1 HWY | ||||||||
| Address2: | |||||||||
| City: | VASS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283949311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102150111 | ||||||||
| FaxNumber: | 9102150113 | ||||||||
| Practice Location | |||||||||
| Address1: | 3349 US 1 HWY | ||||||||
| Address2: | |||||||||
| City: | VASS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283940647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1024576789 | ||||||||
| FaxNumber: | 9102453251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 09/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LX0001X | 201682 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology | 363LF0000X | 201682 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 8902144 | 05 | NC | MEDICAID |