Provider Demographics
NPI:1538778238
Name:LUNDGREN-WALLS, DEBORA (CNM)
Entity type:Individual
Prefix:
First Name:DEBORA
Middle Name:
Last Name:LUNDGREN-WALLS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5750 58TH PL
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-6117
Mailing Address - Country:US
Mailing Address - Phone:808-542-6965
Mailing Address - Fax:
Practice Address - Street 1:3630 ENTERPRISE ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3212
Practice Address - Country:US
Practice Address - Phone:619-299-0840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA236131367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife