Provider Demographics
NPI:1962573394
Name:WALLS, PAMELA SUE (APRN, BC)
Entity type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:SUE
Last Name:WALLS
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Gender:F
Credentials:APRN, BC
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Mailing Address - Street 1:600 22ND AVE NW
Mailing Address - Street 2:SUITE U2
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58703
Mailing Address - Country:US
Mailing Address - Phone:701-721-5143
Mailing Address - Fax:701-839-9071
Practice Address - Street 1:600 22ND AVE NW
Practice Address - Street 2:SUITE U2
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58703
Practice Address - Country:US
Practice Address - Phone:701-721-5143
Practice Address - Fax:701-839-9071
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-163958-0364SP0809X
NDR-29214364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1455317Medicaid
NDN722910Medicare UPIN