Provider Demographics
NPI:1336292325
Name:WALL, KATHLEEN (CRNA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6485 MORGAN LA FEE LN
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-1644
Mailing Address - Country:US
Mailing Address - Phone:239-433-1749
Mailing Address - Fax:
Practice Address - Street 1:6485 MORGAN LA FEE LN
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-1644
Practice Address - Country:US
Practice Address - Phone:239-433-1749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-21
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 1389652367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL034758200Medicaid
FLG0354Medicare PIN