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General NPI Number Information
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NPI Number | 1104138890
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Entity Type | Individual
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Provider Name | JENNIFER LYNN WALLS MD
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Gender | Female
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Dates
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Enumeration Date | 07/09/2010
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Last Update Date | 03/30/2021
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Provider Practice Location Address
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Address Line | 9981 S HEALTHPARK DR
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City | FORT MYERS
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State | FL
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Zip | 33908-3618
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Country | US
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Telephone | 239-343-6260
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Fax | 239-343-6259
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Provider Business Mailing Address
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Address Line | PO BOX 2147
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City | FORT MYERS
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State | FL
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Zip | 33902-2147
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Country | US
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Telephone | 239-343-6260
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Fax | 239-343-6259
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | DR.0056229
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License Number State | CO
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | E-11128
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License Number State | AR
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Taxonomy #3
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 29629
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License Number State | OK
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Taxonomy #4
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Taxonomy Code | 2080P0204X
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Taxonomy Name | Pediatric Emergency Medicine (Pediatrics) Physician
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License Number | ME141875
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License Number State | FL
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