Provider Demographics
NPI:1801966916
Name:WALLS, NANETTA R (PHD)
Entity type:Individual
Prefix:DR
First Name:NANETTA
Middle Name:R
Last Name:WALLS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
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Mailing Address - Street 1:5366 ESTATE OFFICE DRIVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-0611
Mailing Address - Country:US
Mailing Address - Phone:901-508-5257
Mailing Address - Fax:901-388-1995
Practice Address - Street 1:5366 ESTATE OFFICE DRIVE
Practice Address - Street 2:SUITE 3
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-0611
Practice Address - Country:US
Practice Address - Phone:901-508-5257
Practice Address - Fax:901-388-1995
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2020-10-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TNP001065103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07454015Medicaid
TN50159OtherBCBS OF TN
TN3387193Medicaid
TN50159OtherBCBS OF TN
MS07454015Medicaid
TN3387193Medicaid