Provider Demographics
NPI:1619088895
Name:WALL-FEYEN, TAMI L (DC)
Entity Type:Individual
Prefix:DR
First Name:TAMI
Middle Name:L
Last Name:WALL-FEYEN
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 1:470 SOUTH WATER STREET
Mailing Address - Street 2:
Mailing Address - City:PLATTEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53818
Mailing Address - Country:US
Mailing Address - Phone:608-348-3156
Mailing Address - Fax:608-348-3176
Practice Address - Street 1:470 SOUTH WATER STREET
Practice Address - Street 2:
Practice Address - City:PLATTEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53818
Practice Address - Country:US
Practice Address - Phone:608-348-3156
Practice Address - Fax:608-348-3176
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2353012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38836600Medicaid
WI12827OtherDEAN HEALTH PLAN
WI000235395Medicare ID - Type Unspecified
WI38836600Medicaid