Provider Demographics
NPI:1275598864
Name:WALLIS, AMY D (FNP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:D
Last Name:WALLIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:D
Other - Last Name:TROLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5409 AVENUE O
Mailing Address - Street 2:
Mailing Address - City:FORT MADISON
Mailing Address - State:IA
Mailing Address - Zip Code:52627-9601
Mailing Address - Country:US
Mailing Address - Phone:319-376-2134
Mailing Address - Fax:319-376-2188
Practice Address - Street 1:5409 AVENUE O
Practice Address - Street 2:
Practice Address - City:FORT MADISON
Practice Address - State:IA
Practice Address - Zip Code:52627-9601
Practice Address - Country:US
Practice Address - Phone:319-376-2134
Practice Address - Fax:319-376-2188
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002282A363LF0000X
IA100507363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1275598864OtherWELLMARK BLUE CROSS BLUE SHIELD
IA1275598864Medicaid
INP00456554OtherRAILROAD MEDICARE
IN200848020AMedicaid
INCG3197OtherMEDCARE RAILROAD GROUP
IA1275598864OtherWELLMARK BLUE CROSS BLUE SHIELD
IN941190A6Medicare PIN
IA511790018Medicare PIN