Healthcare Provider Details

I. General information

NPI: 1609817089
Provider Name (Legal Business Name): RENEE ANN WALLESEN D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 08/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 W 3RD ST
ALLIANCE NE
69301-3301
US

IV. Provider business mailing address

PO BOX 1496
ANGORA NE
69331-1496
US

V. Phone/Fax

Practice location:
  • Phone: 308-762-9333
  • Fax: 308-762-2223
Mailing address:
  • Phone: 308-762-9333
  • Fax: 308-762-2223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number020578261
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: