Provider Demographics
NPI:1659600039
Name:WALLS, ELIZABETH JEAN (ANP-BC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:JEAN
Last Name:WALLS
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:JEAN
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:252 CHAPMAN RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19702-5438
Mailing Address - Country:US
Mailing Address - Phone:302-623-1929
Mailing Address - Fax:302-366-1075
Practice Address - Street 1:BUILDING B-86
Practice Address - Street 2:OMEGA DR
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-6004
Practice Address - Country:US
Practice Address - Phone:302-366-7665
Practice Address - Fax:302-366-0734
Is Sole Proprietor?:No
Enumeration Date:2009-12-15
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DELB0000230363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
DELB0000230OtherDE PROFESSIONAL LICENSE
DE1659600039Medicaid
DE172700ZA7AMedicare PIN