Provider Demographics
NPI:1912546466
Name:WALL, KAELEN CHRISTINE (RN)
Entity Type:Individual
Prefix:
First Name:KAELEN
Middle Name:CHRISTINE
Last Name:WALL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 2ND ST W
Mailing Address - Street 2:
Mailing Address - City:POLSON
Mailing Address - State:MT
Mailing Address - Zip Code:59860-5314
Mailing Address - Country:US
Mailing Address - Phone:406-261-7380
Mailing Address - Fax:
Practice Address - Street 1:5 4TH AVE E
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860-2117
Practice Address - Country:US
Practice Address - Phone:406-745-3525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-02
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT146223163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse