Healthcare Provider Details

I. General information

NPI: 1952798134
Provider Name (Legal Business Name): DANETTE WALL DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2015
Last Update Date: 04/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10133 QUEENS PARK DR
TAMPA FL
33647-3166
US

IV. Provider business mailing address

10133 QUEENS PARK DR
TAMPA FL
33647-3166
US

V. Phone/Fax

Practice location:
  • Phone: 813-856-9471
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number9333015
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number481063-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number9333015
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number481063-1
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number481063-1
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number9333015
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: