Provider Demographics
NPI:1295000115
Name:WALL, DENISE M (LPN, IBCLC, RLC)
Entity Type:Individual
Prefix:MRS
First Name:DENISE
Middle Name:M
Last Name:WALL
Suffix:
Gender:F
Credentials:LPN, IBCLC, RLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 CROSS CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:VA
Mailing Address - Zip Code:22963-4904
Mailing Address - Country:US
Mailing Address - Phone:434-962-7414
Mailing Address - Fax:
Practice Address - Street 1:519 CROSS CREEK WAY
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:VA
Practice Address - Zip Code:22963-4904
Practice Address - Country:US
Practice Address - Phone:434-962-7414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-09
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA11010140174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN