Provider Demographics
NPI:1720300734
Name:WALLEY, JENNIFER NICOLE (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:NICOLE
Last Name:WALLEY
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 465
Mailing Address - Street 2:
Mailing Address - City:MILLRY
Mailing Address - State:AL
Mailing Address - Zip Code:36558-0465
Mailing Address - Country:US
Mailing Address - Phone:251-846-3233
Mailing Address - Fax:251-846-3224
Practice Address - Street 1:73 LONG STREET
Practice Address - Street 2:
Practice Address - City:MILLRY
Practice Address - State:AL
Practice Address - Zip Code:36558-4564
Practice Address - Country:US
Practice Address - Phone:251-846-3233
Practice Address - Fax:251-846-3224
Is Sole Proprietor?:No
Enumeration Date:2010-02-17
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-092094163W00000X
MSR864418363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05485262Medicaid