Provider Demographics
NPI:1376800235
Name:VAN DE WALLE, ANNESSA FAYE (FNP)
Entity Type:Individual
Prefix:
First Name:ANNESSA
Middle Name:FAYE
Last Name:VAN DE WALLE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:ANNESSA
Other - Middle Name:FAYE
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:291 HARRIS DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78737-4606
Mailing Address - Country:US
Mailing Address - Phone:817-366-7542
Mailing Address - Fax:
Practice Address - Street 1:291 HARRIS DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78737-4606
Practice Address - Country:US
Practice Address - Phone:817-366-7542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-17
Last Update Date:2012-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX618160363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily