Provider Demographics
NPI:1376058511
Name:WALLS, STEPHANIE NICOLE
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:NICOLE
Last Name:WALLS
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:STEPHANIE
Other - Middle Name:NICOLE
Other - Last Name:WALLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:RR 2 BOX 171-A
Mailing Address - Street 2:
Mailing Address - City:ONA
Mailing Address - State:WV
Mailing Address - Zip Code:25545
Mailing Address - Country:US
Mailing Address - Phone:304-356-4562
Mailing Address - Fax:304-558-4563
Practice Address - Street 1:RR 2
Practice Address - Street 2:BOX 171-A
Practice Address - City:ONA
Practice Address - State:WV
Practice Address - Zip Code:25545
Practice Address - Country:US
Practice Address - Phone:304-690-0136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-11
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant