Healthcare Provider Details

I. General information

NPI: 1164036265
Provider Name (Legal Business Name): RAQUEL WALL NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2020
Last Update Date: 07/11/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1490 E FOREMASTER DR STE 320
SAINT GEORGE UT
84790-4505
US

IV. Provider business mailing address

1490 E FOREMASTER DR STE 320
SAINT GEORGE UT
84790-4505
US

V. Phone/Fax

Practice location:
  • Phone: 435-359-3115
  • Fax: 435-319-7123
Mailing address:
  • Phone: 435-359-3115
  • Fax: 435-319-7123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number217908-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: