=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952672404
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMY D WALDEN PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2012
-----------------------------------------------------
Last Update Date | 01/14/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13230 HARRELL PKWY
-----------------------------------------------------
City | NOBLESVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46060-3317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-770-1633
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11537 HANBURY MANOR BLVD
-----------------------------------------------------
City | NOBLESVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46060-7180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-770-9828
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. AMY D WALDEN
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 317-770-9828
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 18002878
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------