=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457919052
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMILY WALSH OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2019
-----------------------------------------------------
Last Update Date | 05/30/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 135 E 38TH ST
-----------------------------------------------------
City | ERIE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16504-1559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-860-2789
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4024 HARMONY RD
-----------------------------------------------------
City | SHANNONVILLE
-----------------------------------------------------
State | ONTARIO
-----------------------------------------------------
Zip | K0K3A0
-----------------------------------------------------
Country | CA
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 390200000X
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------