Healthcare Provider Details

I. General information

NPI: 1457394694
Provider Name (Legal Business Name): ELEANOR ANDREA WALLEN D.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 09/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4418 VINELAND AVE SUITE 215
TOLUCA LAKE CA
91602-3457
US

IV. Provider business mailing address

4418 VINELAND AVE SUITE 215
TOLUCA LAKE CA
91602-2159
US

V. Phone/Fax

Practice location:
  • Phone: 818-980-3383
  • Fax: 818-980-5383
Mailing address:
  • Phone: 818-980-3383
  • Fax: 818-980-5383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE3573
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: