Provider Demographics
NPI:1639796766
Name:WALL, COURTNEY PAIGE (PMHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:PAIGE
Last Name:WALL
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:MISS
Other - First Name:COURTNEY
Other - Middle Name:PAIGE
Other - Last Name:SCHULT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PMHNP-BC
Mailing Address - Street 1:2650 OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-1424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2650 OLIVE ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-1489
Practice Address - Country:US
Practice Address - Phone:314-533-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-06
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020019958363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health