Healthcare Provider Details

I. General information

NPI: 1831581222
Provider Name (Legal Business Name): AMY DIANNA WALLEN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2015
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 S WASHINGTON ST
FARMINGTON MO
63640-1836
US

IV. Provider business mailing address

203 S WASHINGTON ST
FARMINGTON MO
63640-1836
US

V. Phone/Fax

Practice location:
  • Phone: 573-664-1047
  • Fax:
Mailing address:
  • Phone: 573-664-1047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2015006782
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: