=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023515327
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ASHLEY BROOKE WALLEN PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2018
-----------------------------------------------------
Last Update Date | 04/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11819 MIRACLE HILLS DR STE 105
-----------------------------------------------------
City | OMAHA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68154-4428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-905-2075
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3597 W CHERRY RD
-----------------------------------------------------
City | PICKRELL
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68422-8091
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-239-2775
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 2228
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------