Provider Demographics
NPI:1083152136
Name:WALL, ERICA (PMHNP)
Entity Type:Individual
Prefix:MRS
First Name:ERICA
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12037-1127
Mailing Address - Country:US
Mailing Address - Phone:518-364-5854
Mailing Address - Fax:
Practice Address - Street 1:23 HIGH ST
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:NY
Practice Address - Zip Code:12037-1127
Practice Address - Country:US
Practice Address - Phone:518-364-5854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-09
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY404981363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty