Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LW0102X | Nurse Practitioner - Women's Health | 2004020175 | MO |
NPI | 1023252707 |
---|---|
Provider Name | Tram T Wallen |
First Address | Saint Louis, MO 63110-1038 |
Second Address | Saint Louis, MO 63110-1038 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/04/2009 |
Last Update Date | 19/05/2020 |