Provider Demographics
NPI:1063658284
Name:GEORGE E WAHLEN VA
Entity Type:Organization
Organization Name:GEORGE E WAHLEN VA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF NURSE
Authorized Official - Prefix:
Authorized Official - First Name:JANMARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:RN, CDE
Authorized Official - Phone:801-582-1565
Mailing Address - Street 1:VA SLC HCS
Mailing Address - Street 2:500 FOOTHILL BLVD
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84148-0001
Mailing Address - Country:US
Mailing Address - Phone:801-582-1565
Mailing Address - Fax:801-584-2576
Practice Address - Street 1:VA SLC HCS
Practice Address - Street 2:500 FOOTHILL BLVD
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84148-0001
Practice Address - Country:US
Practice Address - Phone:801-582-1565
Practice Address - Fax:801-584-2576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-17
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2085793102163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Single Specialty