Provider Demographics
NPI:1538495262
Name:WALL, GAYLENE O (CNA)
Entity type:Individual
Prefix:
First Name:GAYLENE
Middle Name:O
Last Name:WALL
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:GAYLENE
Other - Middle Name:O
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNA
Mailing Address - Street 1:6393 W 4600 S
Mailing Address - Street 2:
Mailing Address - City:HOOPER
Mailing Address - State:UT
Mailing Address - Zip Code:84315-6753
Mailing Address - Country:US
Mailing Address - Phone:801-985-7585
Mailing Address - Fax:
Practice Address - Street 1:6393 W 4600 S
Practice Address - Street 2:
Practice Address - City:HOOPER
Practice Address - State:UT
Practice Address - Zip Code:84315-6753
Practice Address - Country:US
Practice Address - Phone:801-985-7585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-30
Last Update Date:2009-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTUT000212840909374U00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No374U00000XNursing Service Related ProvidersHome Health Aide