Healthcare Provider Details

I. General information

NPI: 1649628553
Provider Name (Legal Business Name): KENNY JOE WALLEN D.N.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2016
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 STATE HWY 91 S
DILLON MT
59725-7379
US

IV. Provider business mailing address

386 WHITE HORSE LOOP
BOZEMAN MT
59718-1223
US

V. Phone/Fax

Practice location:
  • Phone: 406-683-3000
  • Fax:
Mailing address:
  • Phone: 918-906-1697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number132231
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number132231
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: