Provider Demographics
NPI:1104558386
Name:VAN DE WALLE, ANN COOK (MED)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:COOK
Last Name:VAN DE WALLE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3063 FOREST DR
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44124-5125
Mailing Address - Country:US
Mailing Address - Phone:216-544-4751
Mailing Address - Fax:
Practice Address - Street 1:5905 BRECKSVILLE RD
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-1517
Practice Address - Country:US
Practice Address - Phone:216-524-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program