Provider Demographics
NPI:1659191906
Name:WALL, DONALD VINCENT (CNP)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:VINCENT
Last Name:WALL
Suffix:
Gender:
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:534 ENCHANTED LAKES DR
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-5626
Mailing Address - Country:US
Mailing Address - Phone:702-513-9070
Mailing Address - Fax:
Practice Address - Street 1:2501 N STOCKTON HILL RD STE 108
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-4140
Practice Address - Country:US
Practice Address - Phone:928-255-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-11
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ313585363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily