Provider Demographics
NPI:1902611171
Name:WALZ, CHANNA JAYDE
Entity type:Individual
Prefix:
First Name:CHANNA
Middle Name:JAYDE
Last Name:WALZ
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 146
Mailing Address - Street 2:
Mailing Address - City:OVERTON
Mailing Address - State:NE
Mailing Address - Zip Code:68863-0146
Mailing Address - Country:US
Mailing Address - Phone:308-708-3666
Mailing Address - Fax:
Practice Address - Street 1:236 160TH ST
Practice Address - Street 2:
Practice Address - City:FORT SCOTT
Practice Address - State:KS
Practice Address - Zip Code:66701-8761
Practice Address - Country:US
Practice Address - Phone:308-708-3666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-12
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula