Provider Demographics
NPI:1831581222
Name:WALLEN, AMY DIANNA (FNP)
Entity type:Individual
Prefix:MS
First Name:AMY
Middle Name:DIANNA
Last Name:WALLEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
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Mailing Address - Street 1:2215 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-4403
Mailing Address - Country:US
Mailing Address - Phone:573-271-5317
Mailing Address - Fax:573-335-6724
Practice Address - Street 1:10 LAKE DR
Practice Address - Street 2:
Practice Address - City:BONNE TERRE
Practice Address - State:MO
Practice Address - Zip Code:63628-1820
Practice Address - Country:US
Practice Address - Phone:573-271-5317
Practice Address - Fax:573-335-6724
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-23
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2015006782363L00000X
IL041382502163W00000X
MO2004029063163WH0500X
CA95002093363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No163WH0500XNursing Service ProvidersRegistered NurseHemodialysis
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420021276Medicaid
MO1831581222OtherNPI