Provider Demographics
NPI:1134629538
Name:WALLS, DWAYNE (RN)
Entity type:Individual
Prefix:
First Name:DWAYNE
Middle Name:
Last Name:WALLS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 RB WILSON DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGDON
Mailing Address - State:TN
Mailing Address - Zip Code:38344-1727
Mailing Address - Country:US
Mailing Address - Phone:731-986-7096
Mailing Address - Fax:731-986-7088
Practice Address - Street 1:631 RB WILSON DR
Practice Address - Street 2:
Practice Address - City:HUNTINGDON
Practice Address - State:TN
Practice Address - Zip Code:38344-1727
Practice Address - Country:US
Practice Address - Phone:731-986-7096
Practice Address - Fax:731-986-7088
Is Sole Proprietor?:No
Enumeration Date:2018-02-13
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000130594163WN1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WN1003XNursing Service ProvidersRegistered NurseNutrition Support