Provider Demographics
NPI:1861740219
Name:WALL, VIRGINIA R (RN, MN, IBCLC)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:R
Last Name:WALL
Suffix:
Gender:F
Credentials:RN, MN, IBCLC
Other - Prefix:
Other - First Name:GINNA
Other - Middle Name:
Other - Last Name:WALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN, MN, IBCLC
Mailing Address - Street 1:1959 NE PACIFIC ST
Mailing Address - Street 2:MAILBOX 356079
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98195-0001
Mailing Address - Country:US
Mailing Address - Phone:206-598-4628
Mailing Address - Fax:206-598-2939
Practice Address - Street 1:1959 NE PACIFIC ST
Practice Address - Street 2:MAILBOX 356079
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-0001
Practice Address - Country:US
Practice Address - Phone:206-598-4628
Practice Address - Fax:206-598-2939
Is Sole Proprietor?:No
Enumeration Date:2012-08-15
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00072084163W00000X, 163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163W00000XNursing Service ProvidersRegistered Nurse