Provider Demographics
NPI:1780807891
Name:WALLA, IRIS JENELL (RN)
Entity type:Individual
Prefix:MRS
First Name:IRIS
Middle Name:JENELL
Last Name:WALLA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:IRIS
Other - Middle Name:JENELL
Other - Last Name:WALLA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 856
Mailing Address - Street 2:1211 STONEGATE LANE
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74502-0856
Mailing Address - Country:US
Mailing Address - Phone:918-426-7800
Mailing Address - Fax:918-426-5526
Practice Address - Street 1:1100 E. MONROE
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74502-0579
Practice Address - Country:US
Practice Address - Phone:918-426-7800
Practice Address - Fax:918-426-5526
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR 0050753163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health