Provider Demographics
NPI:1043095649
Name:WALDERA, JAMIE LAIRD (APRN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LAIRD
Last Name:WALDERA
Suffix:
Gender:F
Credentials:APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2504 HASS ST
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-7624
Mailing Address - Country:US
Mailing Address - Phone:608-385-7504
Mailing Address - Fax:
Practice Address - Street 1:855 MANKATO AVE
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-4868
Practice Address - Country:US
Practice Address - Phone:597-457-4484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10728363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health