Healthcare Provider Details

I. General information

NPI: 1275598864
Provider Name (Legal Business Name): AMY D WALLIS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY D TROLAND

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 10/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5409 AVENUE O
FORT MADISON IA
52627-9601
US

IV. Provider business mailing address

5409 AVENUE O
FORT MADISON IA
52627-9601
US

V. Phone/Fax

Practice location:
  • Phone: 319-376-2134
  • Fax: 319-376-2188
Mailing address:
  • Phone: 319-376-2134
  • Fax: 319-376-2188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71002282A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number100507
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1275598864
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerWELLMARK BLUE CROSS BLUE SHIELD
# 2
Identifier1275598864
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer
# 3
IdentifierP00456554
Identifier TypeOTHER
Identifier StateIN
Identifier IssuerRAILROAD MEDICARE
# 4
Identifier200848020A
Identifier TypeMEDICAID
Identifier StateIN
Identifier Issuer
# 5
IdentifierCG3197
Identifier TypeOTHER
Identifier StateIN
Identifier IssuerMEDCARE RAILROAD GROUP

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: