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General NPI Number Information
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NPI Number | 1104276948
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Entity Type | Individual
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Provider Name | ALICIA ANNE VANDEWALLE APRN
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Gender | Female
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Dates
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Enumeration Date | 06/13/2016
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Last Update Date | 08/19/2022
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Provider Practice Location Address
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Address Line | 106 E WAYNE ST
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City | RANDOLPH
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State | NE
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Zip | 68771-5300
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Country | US
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Telephone | 402-337-0200
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 429 402 N MAPLE
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City | OSMOND
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State | NE
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Zip | 68765-0429
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Country | US
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Telephone | 402-748-3393
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Fax |
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 112022
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License Number State | NE
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