Provider Demographics
NPI:1386846657
Name:WALL, GLORIA AGNES (RN)
Entity Type:Individual
Prefix:MRS
First Name:GLORIA
Middle Name:AGNES
Last Name:WALL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 N BEAUMONT RD
Mailing Address - Street 2:SUITE 306
Mailing Address - City:PRAIRIE DU CHIEN
Mailing Address - State:WI
Mailing Address - Zip Code:53821-1445
Mailing Address - Country:US
Mailing Address - Phone:608-326-0230
Mailing Address - Fax:608-326-0289
Practice Address - Street 1:225 N BEAUMONT RD
Practice Address - Street 2:SUITE 306
Practice Address - City:PRAIRIE DU CHIEN
Practice Address - State:WI
Practice Address - Zip Code:53821-1445
Practice Address - Country:US
Practice Address - Phone:608-326-0230
Practice Address - Fax:608-326-0289
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50568-30163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI44005700Medicaid
WI41861300Medicaid
WI44005700Medicaid