Provider Demographics
NPI:1053502914
Name:WALLENBURG, KAREN ANN (LPN)
Entity Type:Individual
Prefix:MS
First Name:KAREN
Middle Name:ANN
Last Name:WALLENBURG
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11675 DAVIS RD
Mailing Address - Street 2:
Mailing Address - City:PRATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:14873-9770
Mailing Address - Country:US
Mailing Address - Phone:607-522-7751
Mailing Address - Fax:
Practice Address - Street 1:11675 DAVIS RD
Practice Address - Street 2:
Practice Address - City:PRATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:14873-9770
Practice Address - Country:US
Practice Address - Phone:607-522-7751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY268998-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02888613Medicaid