Provider Demographics
NPI:1467047159
Name:WALLIS, BEVERLY GAIL
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:GAIL
Last Name:WALLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 POINTE ROYALE DR STE 140
Mailing Address - Street 2:
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-3401
Mailing Address - Country:US
Mailing Address - Phone:501-250-3247
Mailing Address - Fax:
Practice Address - Street 1:158 POINTE ROYALE DR STE 140
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-3401
Practice Address - Country:US
Practice Address - Phone:501-250-3247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-04
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist