Individual
JESSICA WALTHALL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PPCNP-BC
Contact information
Practice address
2637 BROADWAY, NEW YORK, NY 10025-5022
(917) 921-6219
Mailing address
2637 BROADWAY, NEW YORK, NY 10025-5022
(917) 921-6219
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
137013
CT
163W00000X
Registered Nurse
727527
NY
363LP0200X
Pediatric Nurse Practitioner
Primary
382872
NY
Other
Enumeration date
05/12/2018
Last updated
01/18/2022
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