Healthcare Provider Details

I. General information

NPI: 1275529570
Provider Name (Legal Business Name): SUZANNE MARIE WALL N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 11/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG 1806 BRANCH MEDICAL CLINIC NAVAL WEAPONS STATION
YORKTOWN VA
23691
US

IV. Provider business mailing address

PO BOX 90 NAVAL WEAPONS STATION
YORKTOWN VA
23690-0090
US

V. Phone/Fax

Practice location:
  • Phone: 757-953-8430
  • Fax: 757-953-8450
Mailing address:
  • Phone: 757-953-8430
  • Fax: 757-953-8450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024165072
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: