Provider Demographics
NPI:1124261680
Name:WALLS, TAMMY LYNN
Entity type:Individual
Prefix:MISS
First Name:TAMMY
Middle Name:LYNN
Last Name:WALLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1523 RITTER ST
Mailing Address - Street 2:APT. A
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-1044
Mailing Address - Country:US
Mailing Address - Phone:618-978-0690
Mailing Address - Fax:
Practice Address - Street 1:1523 RITTER ST
Practice Address - Street 2:APT. A
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-1044
Practice Address - Country:US
Practice Address - Phone:618-978-0690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-14
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist