Healthcare Provider Details

I. General information

NPI: 1407480353
Provider Name (Legal Business Name): GEORGEANN WALLDEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2020
Last Update Date: 10/08/2021
Certification Date: 10/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1544 KUSER RD STE C9
HAMILTON NJ
08619-3830
US

IV. Provider business mailing address

2119 GALLAGHER AVE
SCOTCH PLAINS NJ
07076-2607
US

V. Phone/Fax

Practice location:
  • Phone: 734-373-0849
  • Fax:
Mailing address:
  • Phone: 917-923-4941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00561600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: