Individual
SUSAN P WALLA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
APRN
Contact information
Practice address
707 W 8TH ST, GILLETTE, WY 82716-4108
(307) 685-8255
(888) 852-8319
Mailing address
748 MAIN ST, LANDER, WY 82520-3036
(307) 332-2231
(307) 332-2231
Taxonomy
Speciality
Code
Description
License number
State
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
21112
MT
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
29650.1122
WY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0000439212
—
MT
05
—
136049300
—
WY
Enumeration date
11/01/2006
Last updated
08/24/2016
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