Healthcare Provider Details

I. General information

NPI: 1528373586
Provider Name (Legal Business Name): ANNA D WALLEY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2010
Last Update Date: 03/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MARSHALL STREET SUITE 200
JACKSON MS
39202
US

IV. Provider business mailing address

501 MARSHALL STREET SUITE 200
JACKSON MS
39202
US

V. Phone/Fax

Practice location:
  • Phone: 601-914-9503
  • Fax: 601-914-6174
Mailing address:
  • Phone: 601-914-9503
  • Fax: 601-914-6174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR873502
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: