Provider Demographics
NPI:1104002716
Name:WALL, MICHELLE DANA
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DANA
Last Name:WALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 EXCELSIOR BLVD
Mailing Address - Street 2:407
Mailing Address - City:SAINT LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4960
Mailing Address - Country:US
Mailing Address - Phone:612-296-5174
Mailing Address - Fax:
Practice Address - Street 1:4601 EXCELSIOR BLVD
Practice Address - Street 2:407
Practice Address - City:SAINT LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-4960
Practice Address - Country:US
Practice Address - Phone:612-296-5174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-14
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist