Provider Demographics
NPI:1609817089
Name:WALLESEN, RENEE ANN (DC)
Entity Type:Individual
Prefix:DR
First Name:RENEE
Middle Name:ANN
Last Name:WALLESEN
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:PO BOX 1496
Mailing Address - Street 2:
Mailing Address - City:ANGORA
Mailing Address - State:NE
Mailing Address - Zip Code:69331-1496
Mailing Address - Country:US
Mailing Address - Phone:308-762-9333
Mailing Address - Fax:308-762-2223
Practice Address - Street 1:113 W 3RD ST
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:NE
Practice Address - Zip Code:69301-3301
Practice Address - Country:US
Practice Address - Phone:308-762-9333
Practice Address - Fax:308-762-2223
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE020578261111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE020578261OtherMUTUAL OF OMAHA
NE36634OtherBLUE CROSS BLUE SHIELD
NE232114OtherMIDLANDS CHOICE
NEP00801937OtherRAILROAD MEDICARE PALMETTO
NE232114OtherMIDLANDS CHOICE