Healthcare Provider Details

I. General information

NPI: 1982243630
Provider Name (Legal Business Name): ITAMAR WALL APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2019
Last Update Date: 09/15/2022
Certification Date: 09/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 S OLD DIXIE HWY STE 204
JUPITER FL
33458-7202
US

IV. Provider business mailing address

2718 DANFORTH TER
WELLINGTON FL
33414-3418
US

V. Phone/Fax

Practice location:
  • Phone: 561-517-8678
  • Fax: 561-529-5087
Mailing address:
  • Phone: 561-517-8678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11005498
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: