Provider Demographics
NPI:1386958379
Name:WALLING, CAROL LYNN GATES (MED, , COMS)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:LYNN GATES
Last Name:WALLING
Suffix:
Gender:F
Credentials:MED, , COMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 PLYMOUTH DR APT B
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-6567
Mailing Address - Country:US
Mailing Address - Phone:717-420-0145
Mailing Address - Fax:
Practice Address - Street 1:1109 PLYMOUTH DR APT B
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-6567
Practice Address - Country:US
Practice Address - Phone:717-420-0145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-02
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL857266251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)