Provider Demographics
NPI:1184603045
Name:WALL, DONNA VAN BLADEL (NP)
Entity type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:VAN BLADEL
Last Name:WALL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:DONNA
Other - Middle Name:
Other - Last Name:VAN BLADEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:531 ROSELANE ST NW STE 710
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-6975
Mailing Address - Country:US
Mailing Address - Phone:678-331-3297
Mailing Address - Fax:678-581-7187
Practice Address - Street 1:144 BILL CARRUTH PKWY STE 3100
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-3819
Practice Address - Country:US
Practice Address - Phone:678-363-1940
Practice Address - Fax:678-581-7110
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN134321363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1184603045OtherNPI NUMBER