Healthcare Provider Details

I. General information

NPI: 1255996765
Provider Name (Legal Business Name): EVELYN D WALBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2019
Last Update Date: 05/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 E WALNUT ST
ELLINGTON MO
63638-7943
US

IV. Provider business mailing address

315 E WALNUT ST
ELLINGTON MO
63638-7943
US

V. Phone/Fax

Practice location:
  • Phone: 573-663-2644
  • Fax:
Mailing address:
  • Phone: 573-663-2644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number65672
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: