Provider Demographics
NPI:1073827531
Name:WALLS, AMANDA SUE (OD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:SUE
Last Name:WALLS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:AMANDA
Other - Middle Name:SUE
Other - Last Name:NADOLSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2857 E FOUNTAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-2312
Mailing Address - Country:US
Mailing Address - Phone:719-329-1221
Mailing Address - Fax:
Practice Address - Street 1:2857 E FOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-2312
Practice Address - Country:US
Practice Address - Phone:719-329-1221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-27
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2825152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics