MEDICARE: AMY DIANE WALD FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	2016005843	MO
2	363L00000X	Nurse Practitioner	2016005843	MO

General Provider Information

NPI Number	:	1154781664
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY DIANE WALD FNP-C

Provider Business Mailing Address
First Line	:	1301 SW ARBORWALK BLVD # A
Second Line	:
City	:	LEES SUMMIT
State	:	MO
Zip	:	64082-4101
Country	:	US
Telephone Number	:	816-537-6232
Fax Number	:	816-537-9161

Provider Business Practice Location Address
First Line	:	1301 SW ARBORWALK BLVD STE A
Second Line	:
City	:	LEES SUMMIT
State	:	MO
Zip	:	64082-4101
Country	:	US
Telephone Number	:	816-537-6232
Fax Number	:	816-537-9161

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/25/2016
Last Update Date	:	01/28/2022

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