Healthcare Provider Details

I. General information

NPI: 1639158264
Provider Name (Legal Business Name): ELIZABETH ANN WALL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 09/08/2025
Certification Date: 09/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

722 SOUTH COLLEGE AVENUE
COLLEGE PLACE WA
99324
US

IV. Provider business mailing address

722 S COLLEGE AVE
COLLEGE PLACE WA
99324-1519
US

V. Phone/Fax

Practice location:
  • Phone: 509-524-8023
  • Fax: 509-691-6317
Mailing address:
  • Phone: 509-524-8023
  • Fax: 509-691-6317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP60334140
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number087000077N1
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: