Provider Demographics
NPI:1164036265
Name:WALL, RAQUEL (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1490 E FOREMASTER DR STE 320
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-4505
Mailing Address - Country:US
Mailing Address - Phone:435-359-3115
Mailing Address - Fax:
Practice Address - Street 1:1490 E FOREMASTER DR STE 320
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-4505
Practice Address - Country:US
Practice Address - Phone:435-359-3115
Practice Address - Fax:435-291-1096
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-04
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT217908-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily