Provider Demographics
NPI:1649628553
Name:WALLEN, KENNY JOE (DNP)
Entity type:Individual
Prefix:
First Name:KENNY
Middle Name:JOE
Last Name:WALLEN
Suffix:
Gender:M
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:386 WHITE HORSE LOOP
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-1223
Mailing Address - Country:US
Mailing Address - Phone:918-906-1697
Mailing Address - Fax:
Practice Address - Street 1:600 STATE HWY 91 S
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:MT
Practice Address - Zip Code:59725-7379
Practice Address - Country:US
Practice Address - Phone:406-683-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-01
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT132231367500000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine