Provider Demographics
NPI:1154588861
Name:WALL, MARLA LOREE
Entity type:Individual
Prefix:
First Name:MARLA
Middle Name:LOREE
Last Name:WALL
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:PO BOX 278
Mailing Address - Street 2:
Mailing Address - City:ALTO
Mailing Address - State:NM
Mailing Address - Zip Code:88312-0278
Mailing Address - Country:US
Mailing Address - Phone:575-973-4973
Mailing Address - Fax:
Practice Address - Street 1:147 MESCALERO TRL
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-6090
Practice Address - Country:US
Practice Address - Phone:575-257-5820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist