Provider Demographics
NPI:1588674717
Name:GOULD, WALLENA M (CRNA)
Entity Type:Individual
Prefix:
First Name:WALLENA
Middle Name:M
Last Name:GOULD
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:WALLENA
Other - Middle Name:M
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 650782
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0782
Mailing Address - Country:US
Mailing Address - Phone:302-733-0806
Mailing Address - Fax:302-733-0854
Practice Address - Street 1:1505 W SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-6912
Practice Address - Country:US
Practice Address - Phone:856-641-8000
Practice Address - Fax:856-641-7668
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00243400367500000X
NJ26NR08657200163W00000X
PARN502167L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102332049Medicaid
072989OtherAANA NUMBER
NJP00795663OtherRAILROAD MEDICARE
NJ186756Medicare PIN
072989OtherAANA NUMBER