Healthcare Provider Details

I. General information

NPI: 1619771250
Provider Name (Legal Business Name): MIRACLE ANN WALLS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2025
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 MADISON AVE STE 447
MEMPHIS TN
38103-3438
US

IV. Provider business mailing address

3074 NATHAN AVE APT 5
MEMPHIS TN
38112-3660
US

V. Phone/Fax

Practice location:
  • Phone: 901-287-6756
  • Fax:
Mailing address:
  • Phone: 901-614-7628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: