Provider Demographics
NPI:1841633260
Name:WALLS, ANDREA M (CCSS)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:M
Last Name:WALLS
Suffix:
Gender:F
Credentials:CCSS
Other - Prefix:MISS
Other - First Name:ANDREA
Other - Middle Name:MICHELLE
Other - Last Name:WALLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCSS
Mailing Address - Street 1:P.O. BOX 1 - FISCAL SERVICES
Mailing Address - Street 2:3550 HIGHWAY, 468 WEST
Mailing Address - City:WHITFIELD
Mailing Address - State:MS
Mailing Address - Zip Code:39193-0157
Mailing Address - Country:US
Mailing Address - Phone:601-351-8000
Mailing Address - Fax:
Practice Address - Street 1:3550 HIGHWAY, 468 WEST
Practice Address - Street 2:FISCAL SERVICES
Practice Address - City:WHITFIELD
Practice Address - State:MS
Practice Address - Zip Code:39193-0157
Practice Address - Country:US
Practice Address - Phone:601-351-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-16
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1015171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator