Healthcare Provider Details

I. General information

NPI: 1306572581
Provider Name (Legal Business Name): WELLEY WALLO RT/MT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2022
Last Update Date: 07/28/2022
Certification Date: 07/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1065 SOUTHERN BLVD
BRONX NY
10459-2417
US

IV. Provider business mailing address

1065 SOUTHERN BLVD
BRONX NY
10459-2417
US

V. Phone/Fax

Practice location:
  • Phone: 718-589-2440
  • Fax:
Mailing address:
  • Phone: 718-589-2440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2471M2300X
TaxonomyMammography Radiologic Technologist
License Number
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License Number243600
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: