Provider Demographics
NPI:1609395441
Name:WALSH, CLARISSA FAYE
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:FAYE
Last Name:WALSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CLARISSA
Other - Middle Name:FAYE
Other - Last Name:CALLAHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:510 W 29TH ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-2760
Mailing Address - Country:US
Mailing Address - Phone:307-426-4728
Mailing Address - Fax:
Practice Address - Street 1:2310 E 8TH ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001
Practice Address - Country:US
Practice Address - Phone:307-632-6433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-13
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker