Provider Demographics
NPI:1447218540
Name:WALLEN, BETH ANNE (MD)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:ANNE
Last Name:WALLEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 858
Mailing Address - Street 2:MC A410
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-0858
Mailing Address - Country:US
Mailing Address - Phone:800-243-1455
Mailing Address - Fax:
Practice Address - Street 1:845 FISHBURN RD
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2015
Practice Address - Country:US
Practice Address - Phone:717-531-8181
Practice Address - Fax:717-531-3509
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD052735L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014823610006Medicaid
PA0014823610006Medicaid
F88299Medicare UPIN