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NPI Code Detail

MEDICARE: NICOLA CLARKE WALLEN PMHNP

MEDICARE: NICOLA CLARKE WALLEN PMHNP
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
1363LP0808XPsychiatric/Mental Health Nurse PractitionerR190596MD

General Provider Information

NPI Number : 1659413615
Entity Type Code : Individual
Provider Name (Legal Business Name) : NICOLA CLARKE WALLEN PMHNP
Provider Business Mailing Address
First Line : 3307 DUNWOOD RIDGE TER
Second Line :
City : BOWIE
State : MD
Zip : 20721-1259
Country : US
Telephone Number : 202-569-2638
Fax Number :
Provider Business Practice Location Address
First Line : 3261 OLD WASHINGTON RD STE 2020
Second Line :
City : WALDORF
State : MD
Zip : 20602-3231
Country : US
Telephone Number : 301-960-8930
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/13/2007
Last Update Date : 08/25/2020

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