Provider Demographics
NPI:1942315940
Name:WALLIS, VALERIE ANN (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:VALERIE
Middle Name:ANN
Last Name:WALLIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 PINEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-2461
Mailing Address - Country:US
Mailing Address - Phone:501-778-7921
Mailing Address - Fax:
Practice Address - Street 1:4300 W 7TH ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5446
Practice Address - Country:US
Practice Address - Phone:501-257-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC00385367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered