Provider Demographics
NPI:1942357942
Name:WALLNER, JILL (MD)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:WALLNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 W FIRST ST
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-4443
Mailing Address - Country:US
Mailing Address - Phone:931-456-7992
Mailing Address - Fax:931-707-1089
Practice Address - Street 1:58 W FIRST ST
Practice Address - Street 2:SUITE 101
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-4443
Practice Address - Country:US
Practice Address - Phone:931-456-7992
Practice Address - Fax:931-707-1089
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD 27432207QA0000X, 207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3097859Medicare ID - Type Unspecified
TNF12742Medicare UPIN