Healthcare Provider Details

I. General information

NPI: 1023509809
Provider Name (Legal Business Name): STELLA WALLEN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2018
Last Update Date: 05/17/2024
Certification Date: 05/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 BEAUVOIR AVE
SUMMIT NJ
07901-3533
US

IV. Provider business mailing address

99 BEAUVOIR AVE
SUMMIT NJ
07901-3533
US

V. Phone/Fax

Practice location:
  • Phone: 908-598-1500
  • Fax:
Mailing address:
  • Phone: 908-265-1539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number26NJ00870200
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NR12940300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: