Healthcare Provider Details

I. General information

NPI: 1649359837
Provider Name (Legal Business Name): JEAN WESTLEY WALL C.P.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 SERENO DR
VALLEJO CA
94589-2441
US

IV. Provider business mailing address

975 SERENO DR
VALLEJO CA
94589-2441
US

V. Phone/Fax

Practice location:
  • Phone: 707-651-3344
  • Fax: 707-651-3355
Mailing address:
  • Phone: 707-651-3344
  • Fax: 707-651-3355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN 191615
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: