Provider Demographics
NPI:1962589747
Name:WALLA, SUSAN P (APRN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:P
Last Name:WALLA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:748 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3036
Mailing Address - Country:US
Mailing Address - Phone:307-332-2231
Mailing Address - Fax:307-332-2231
Practice Address - Street 1:707 W 8TH ST
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-4108
Practice Address - Country:US
Practice Address - Phone:307-685-8255
Practice Address - Fax:888-852-8319
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT21112363LP0808X
WY29650.1122363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000439212Medicaid
WY136049300Medicaid