Provider Demographics
NPI:1508138843
Name:WALLI, JOHN ROBERT (NURSE PRACTIONER)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:WALLI
Suffix:
Gender:M
Credentials:NURSE PRACTIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16443 DELIA DR
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-9411
Mailing Address - Country:US
Mailing Address - Phone:228-860-5164
Mailing Address - Fax:
Practice Address - Street 1:16443 DELIA DR
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-9411
Practice Address - Country:US
Practice Address - Phone:228-861-8505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-02
Last Update Date:2019-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR850026363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily