Provider Demographics
NPI:1760620298
Name:WALL, CHRISTINE ANN (RN)
Entity Type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:ANN
Last Name:WALL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:CHRISTINE
Other - Middle Name:ANN
Other - Last Name:SICURELLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:110 S PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18701-3301
Mailing Address - Country:US
Mailing Address - Phone:570-552-6000
Mailing Address - Fax:570-552-6021
Practice Address - Street 1:110 S PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18701-3301
Practice Address - Country:US
Practice Address - Phone:570-552-6000
Practice Address - Fax:570-552-6021
Is Sole Proprietor?:No
Enumeration Date:2009-01-21
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN318692L163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse