Healthcare Provider Details

I. General information

NPI: 1306898903
Provider Name (Legal Business Name): ELIZABETH A WALENZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 01/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10060 REGENCY CIR
OMAHA NE
68114-3732
US

IV. Provider business mailing address

PO BOX 3755
OMAHA NE
68103-0755
US

V. Phone/Fax

Practice location:
  • Phone: 400-235-4132
  • Fax: 402-354-1301
Mailing address:
  • Phone: 402-354-2100
  • Fax: 402-354-2155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number46311
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number23702
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: