Basic Information
| Provider Information | |||||||||
| NPI: | 1912546466 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALL | ||||||||
| FirstName: | KAELEN | ||||||||
| MiddleName: | CHRISTINE | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1202 2ND ST W | ||||||||
| Address2: | |||||||||
| City: | POLSON | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598605314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062617380 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5 4TH AVE E | ||||||||
| Address2: | |||||||||
| City: | POLSON | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598602117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067453525 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2020 | ||||||||
| LastUpdateDate: | 01/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 146223 | MT | Y | Nursing Service Providers | Registered Nurse |
No ID Information.