Healthcare Provider Details

I. General information

NPI: 1902886187
Provider Name (Legal Business Name): JANET WALLECK CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 12/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WVU HOSP 1 MEDICAL DRIVE
MORGANTOWN WV
26506
US

IV. Provider business mailing address

303 MUNNELL STREET
CANONSBURG PA
15317
US

V. Phone/Fax

Practice location:
  • Phone: 304-598-4000
  • Fax:
Mailing address:
  • Phone: 724-809-4033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN328553L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number60816
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: