Provider Demographics
NPI:1619771250
Name:WALLS, MIRACLE ANN (DO)
Entity type:Individual
Prefix:
First Name:MIRACLE
Middle Name:ANN
Last Name:WALLS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3074 NATHAN AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38112-3660
Mailing Address - Country:US
Mailing Address - Phone:901-614-7628
Mailing Address - Fax:
Practice Address - Street 1:920 MADISON AVE STE 447
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-3438
Practice Address - Country:US
Practice Address - Phone:901-287-6756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-02
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program