Provider Demographics
NPI:1639158264
Name:WALL, ELIZABETH ANN (NP)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:ANN
Last Name:WALL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 S COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:99324-1519
Mailing Address - Country:US
Mailing Address - Phone:509-524-8023
Mailing Address - Fax:509-691-6317
Practice Address - Street 1:722 SOUTH COLLEGE AVENUE
Practice Address - Street 2:
Practice Address - City:COLLEGE PLACE
Practice Address - State:WA
Practice Address - Zip Code:99324
Practice Address - Country:US
Practice Address - Phone:509-524-8023
Practice Address - Fax:509-691-6317
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-12
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR087000077N1363LF0000X
AKNURU1281363LF0000X
WAAP60334140363LF0000X
OR87000077364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health