Provider Demographics
NPI:1760816102
Name:WALL, WENDY (NP-C)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 10TH AVE
Mailing Address - Street 2:SUITE 380
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-3700
Mailing Address - Country:US
Mailing Address - Phone:706-324-0471
Mailing Address - Fax:706-324-0473
Practice Address - Street 1:2000 10TH AVE
Practice Address - Street 2:SUITE 380
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-3700
Practice Address - Country:US
Practice Address - Phone:706-324-0471
Practice Address - Fax:706-324-0473
Is Sole Proprietor?:No
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN141043363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner