Provider Demographics
NPI:1013536531
Name:WALQUIST, AMY CHRISTINE
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:CHRISTINE
Last Name:WALQUIST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:CHRISTINE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4138 HIGHWAY TT
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:MO
Mailing Address - Zip Code:64076-6354
Mailing Address - Country:US
Mailing Address - Phone:816-506-8199
Mailing Address - Fax:
Practice Address - Street 1:4138 HIGHWAY TT
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:MO
Practice Address - Zip Code:64076-6354
Practice Address - Country:US
Practice Address - Phone:816-506-8199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-14
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO131713163WN1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WN1003XNursing Service ProvidersRegistered NurseNutrition Support