MEDICARE: ANNESSA FAYE VAN DE WALLE FNP

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	618160	TX

General Provider Information

NPI Number	:	1376800235
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANNESSA FAYE VAN DE WALLE FNP

Provider Business Mailing Address
First Line	:	291 HARRIS DR
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78737-4606
Country	:	US
Telephone Number	:	817-366-7542
Fax Number	:

Provider Business Practice Location Address
First Line	:	291 HARRIS DR
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78737-4606
Country	:	US
Telephone Number	:	817-366-7542
Fax Number	:

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

Provider Enumeration Date	:	04/17/2012
Last Update Date	:	04/17/2012

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