Provider Demographics
NPI:1508370495
Name:WAHL, MARY COLLEEN (ARNP, DNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:COLLEEN
Last Name:WAHL
Suffix:
Gender:F
Credentials:ARNP, DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:532 GREENBAY RD
Mailing Address - Street 2:
Mailing Address - City:CHIPLEY
Mailing Address - State:FL
Mailing Address - Zip Code:32428
Mailing Address - Country:US
Mailing Address - Phone:850-658-4924
Mailing Address - Fax:
Practice Address - Street 1:4455 SAM MITCHELL DR
Practice Address - Street 2:
Practice Address - City:CHIPLEY
Practice Address - State:FL
Practice Address - Zip Code:32428-3501
Practice Address - Country:US
Practice Address - Phone:850-773-0392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-30
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2925992363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health