Provider Demographics
NPI:1194161786
Name:WALL, MARY BERNADETTE (RN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:BERNADETTE
Last Name:WALL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:581 BLUE HERON DR
Mailing Address - Street 2:APT 308B
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-5738
Mailing Address - Country:US
Mailing Address - Phone:917-853-2727
Mailing Address - Fax:
Practice Address - Street 1:27175 HAGGERTY RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-3626
Practice Address - Country:US
Practice Address - Phone:248-799-8303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-22
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9211314163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse