Healthcare Provider Details

I. General information

NPI: 1396016622
Provider Name (Legal Business Name): JAIME CARTER WALLS MA, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2012
Last Update Date: 01/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 MICHIGAN AVE NE
WASHINGTON DC
20064-0001
US

IV. Provider business mailing address

7302 RIVERHILL RD
OXON HILL MD
20745-1031
US

V. Phone/Fax

Practice location:
  • Phone: 202-319-6049
  • Fax: 202-319-4752
Mailing address:
  • Phone: 517-414-9970
  • Fax: 202-319-6049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: