=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245846542
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALANNA MARIE WALLERSTEIN AU.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2020
-----------------------------------------------------
Last Update Date | 09/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2945 HAZELWOOD ST STE 200
-----------------------------------------------------
City | MAPLEWOOD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55109-1243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-232-0707
-----------------------------------------------------
Fax | 651-326-9462
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2945 HAZELWOOD ST STE 200
-----------------------------------------------------
City | MAPLEWOOD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55109-1243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-232-0707
-----------------------------------------------------
Fax | 651-326-9462
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number | 10303
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------