Basic Information
| Provider Information | |||||||||
| NPI: | 1477122414 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALD | ||||||||
| FirstName: | KAYLA | ||||||||
| MiddleName: | GRACE | ||||||||
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| Credential: | AGACNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5927 PENROSE AVE | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752065521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167399864 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3901 W 15TH ST | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750757738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9725966800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2021 | ||||||||
| LastUpdateDate: | 06/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 1045639 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.