Provider Demographics
NPI:1013699248
Name:WALLEN, WILLIAM CHASE
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:CHASE
Last Name:WALLEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 BARCLAYS DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-6077
Mailing Address - Country:US
Mailing Address - Phone:336-978-2029
Mailing Address - Fax:
Practice Address - Street 1:1400 SPRING GARDEN ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27412-5015
Practice Address - Country:US
Practice Address - Phone:336-334-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer