Basic Information
| Provider Information | |||||||||
| NPI: | 1891081816 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALMER | ||||||||
| FirstName: | MARCIA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | RN, AP/MHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2351 25TH ST | ||||||||
| Address2: | UNIT B | ||||||||
| City: | ALAMOGORDO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 883108722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5754465303 | ||||||||
| FaxNumber: | 5754465309 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 N EDWARD ST | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625264163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178766400 | ||||||||
| FaxNumber: | 2178766405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2011 | ||||||||
| LastUpdateDate: | 04/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 002128 | MO | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 163W00000X | 149189 | MO | N | Nursing Service Providers | Registered Nurse | 363LP0808X | 2011016058 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | CNP-63509 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | 209-014459 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 77449 | 01 | MO | MEDICARE PROVIDER NUMBER | OTHER |