Healthcare Provider Details

I. General information

NPI: 1063904464
Provider Name (Legal Business Name): KELSI V WALLA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELSEY V SULLIVAN PA-C

II. Dates (important events)

Enumeration Date: 05/31/2018
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2719
US

IV. Provider business mailing address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2719
US

V. Phone/Fax

Practice location:
  • Phone: 480-751-9804
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2018-0032
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: