Provider Demographics
NPI:1609045566
Name:WALLEN, IDA SUE (DC)
Entity Type:Individual
Prefix:DR
First Name:IDA
Middle Name:SUE
Last Name:WALLEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9375 US HIGHWAY 19 N STE B
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33782-5420
Mailing Address - Country:US
Mailing Address - Phone:727-577-7775
Mailing Address - Fax:727-577-7776
Practice Address - Street 1:9375 US HIGHWAY 19 N STE B
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33782-5420
Practice Address - Country:US
Practice Address - Phone:727-577-7775
Practice Address - Fax:727-577-7776
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH002614111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL88560Medicare UPIN