Basic Information
| Provider Information | |||||||||
| NPI: | 1831581222 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLEN | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | DIANNA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11 S DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | BONNE TERRE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 636281772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737231100 | ||||||||
| FaxNumber: | 5737231130 | ||||||||
| Practice Location | |||||||||
| Address1: | 4921 PARKVIEW PL | ||||||||
| Address2: | 5TH FLOOR SUITE C | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143627603 | ||||||||
| FaxNumber: | 3147475213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2015 | ||||||||
| LastUpdateDate: | 04/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 2015006782 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.