Provider Demographics
NPI:1619901790
Name:WALLIS, DEANNA LORRAINE (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:LORRAINE
Last Name:WALLIS
Suffix:
Gender:F
Credentials:REGISTERED NURSE
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Mailing Address - Street 1:1650 COCHRANE CIRCLE
Mailing Address - Street 2:DEPARTMENT OF THE ARMY USA MEDDAC EVANS ARMY COMMUNITY
Mailing Address - City:FT CARSON
Mailing Address - State:CO
Mailing Address - Zip Code:80913-4604
Mailing Address - Country:US
Mailing Address - Phone:719-526-7649
Mailing Address - Fax:719-526-7019
Practice Address - Street 1:USA MEDDAC EVANS ARMY COMMUNITY HOSPITAL
Practice Address - Street 2:PACL SDS
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4604
Practice Address - Country:US
Practice Address - Phone:719-526-7071
Practice Address - Fax:719-526-7007
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GARN135981163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse