Provider Demographics
NPI:1104316454
Name:WALTHALL, JESSICA (PPCNP-BC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WALTHALL
Suffix:
Gender:F
Credentials:PPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2637 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-5022
Mailing Address - Country:US
Mailing Address - Phone:917-921-6219
Mailing Address - Fax:
Practice Address - Street 1:2637 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-5022
Practice Address - Country:US
Practice Address - Phone:917-921-6219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-12
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT137013163W00000X
NY727527163W00000X
NY382872363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse