Provider Demographics
NPI:1720084486
Name:WALLIN, MARY JEAN (CERTIFIED NURSE MIDW)
Entity type:Individual
Prefix:MISS
First Name:MARY
Middle Name:JEAN
Last Name:WALLIN
Suffix:
Gender:F
Credentials:CERTIFIED NURSE MIDW
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:J
Other - Last Name:STUTSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-6585
Mailing Address - Fax:605-328-6512
Practice Address - Street 1:1500 W 22ND ST STE 301
Practice Address - Street 2:SANFORD HEALTH MATERNAL FETAL MEDICINE CLINIC
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1503
Practice Address - Country:US
Practice Address - Phone:605-328-7700
Practice Address - Fax:605-328-7775
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0023367A00000X
176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6540104Medicaid
SD6540104Medicaid
SD420001803Medicare PIN
SD500029619Medicare PIN
S99360Medicare UPIN