=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942307855
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MONICA JAYNE WALL M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 03/31/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3031 W HORIZON RIDGE PKWY STE 120
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89052-3809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-614-4476
-----------------------------------------------------
Fax | 702-914-7644
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 530245
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89053-0245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-614-4476
-----------------------------------------------------
Fax | 702-914-7644
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 8291
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------