Provider Demographics
NPI:1043284292
Name:WALL, ANDREA S (ACNP)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:S
Last Name:WALL
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:S
Other - Last Name:WALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ARNP
Mailing Address - Street 1:10109 E 79TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-4564
Mailing Address - Country:US
Mailing Address - Phone:918-286-5131
Mailing Address - Fax:918-249-7532
Practice Address - Street 1:10109 E 79TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-4564
Practice Address - Country:US
Practice Address - Phone:918-286-5131
Practice Address - Fax:918-249-7532
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR31459163WS0121X
OKR0086862363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WS0121XNursing Service ProvidersRegistered NursePlastic Surgery