=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043772932
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CONNESUALA WALDEN APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2019
-----------------------------------------------------
Last Update Date | 04/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1241 PT MALLARD PKWY STE 410
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35601-6572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-286-2289
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1241 PT MALLARD PKWY STE 410
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35601-6572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-286-2289
-----------------------------------------------------
Fax | 256-937-2508
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 25546
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------