Healthcare Provider Details

I. General information

NPI: 1609583517
Provider Name (Legal Business Name): ROBERT WALLEN PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2022
Last Update Date: 02/20/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13331 W INDIAN SCHOOL RD STE B203
LITCHFIELD PARK AZ
85340-4340
US

IV. Provider business mailing address

16620 N 40TH ST STE E1
PHOENIX AZ
85032-3357
US

V. Phone/Fax

Practice location:
  • Phone: 623-269-3990
  • Fax:
Mailing address:
  • Phone: 602-464-9576
  • Fax: 480-428-0475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number282633
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: