Provider Demographics
NPI:1457394694
Name:WALLEN, ELEANOR ANDREA (DPM)
Entity Type:Individual
Prefix:
First Name:ELEANOR
Middle Name:ANDREA
Last Name:WALLEN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4418 VINELAND AVE
Mailing Address - Street 2:SUITE 215
Mailing Address - City:TOLUCA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:91602-2159
Mailing Address - Country:US
Mailing Address - Phone:818-980-3383
Mailing Address - Fax:818-980-5383
Practice Address - Street 1:4418 VINELAND AVE
Practice Address - Street 2:SUITE 215
Practice Address - City:TOLUCA LAKE
Practice Address - State:CA
Practice Address - Zip Code:91602-3457
Practice Address - Country:US
Practice Address - Phone:818-980-3383
Practice Address - Fax:818-980-5383
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3573213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW21231OtherMEDICARE PTAN GROUP
CAE3573Medicare ID - Type Unspecified
CAT95609Medicare UPIN