Provider Demographics
NPI:1720154834
Name:WALL, ANNIE K (LMP, CFEP, APP)
Entity Type:Individual
Prefix:MS
First Name:ANNIE
Middle Name:K
Last Name:WALL
Suffix:
Gender:F
Credentials:LMP, CFEP, APP
Other - Prefix:MS
Other - First Name:ANNIE
Other - Middle Name:K
Other - Last Name:WALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP, CFEP, APP
Mailing Address - Street 1:29437 18TH AVENUE SOUTH
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003
Mailing Address - Country:US
Mailing Address - Phone:206-817-2224
Mailing Address - Fax:253-839-8634
Practice Address - Street 1:106 LAKE AVENUE SOUTH
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057
Practice Address - Country:US
Practice Address - Phone:206-817-2224
Practice Address - Fax:253-839-8634
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA7355174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist