Healthcare Provider Details

I. General information

NPI: 1215758487
Provider Name (Legal Business Name): MARIE ADELLA ZUMWALT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2024
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2723 CHRISTENSEN RD
CHEYENNE WY
82007-9662
US

IV. Provider business mailing address

7076 ROAD 55F
TORRINGTON WY
82240-7771
US

V. Phone/Fax

Practice location:
  • Phone: 747-204-6096
  • Fax:
Mailing address:
  • Phone: 307-532-6600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number27180
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number27180
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: