Provider Demographics
NPI:1457847493
Name:WALL, HENRIETTA
Entity Type:Individual
Prefix:
First Name:HENRIETTA
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 S HIGH ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43207-1045
Mailing Address - Country:US
Mailing Address - Phone:614-643-6822
Mailing Address - Fax:
Practice Address - Street 1:1430 S HIGH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43207-1045
Practice Address - Country:US
Practice Address - Phone:614-643-6822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-02
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.437322163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC$$$$$$$$$Medicaid