Provider Demographics
NPI:1083760755
Name:VAN DE WALLE, MYRNA RAE (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MRS
First Name:MYRNA
Middle Name:RAE
Last Name:VAN DE WALLE
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 S TENNESSEE PL
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-5358
Mailing Address - Country:US
Mailing Address - Phone:641-424-6042
Mailing Address - Fax:
Practice Address - Street 1:9184 265TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:CLEAR LAKE
Practice Address - State:IA
Practice Address - Zip Code:50428-8507
Practice Address - Country:US
Practice Address - Phone:641-357-6112
Practice Address - Fax:641-357-3686
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00694225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist