Basic Information
| Provider Information | |||||||||
| NPI: | 1588674717 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOULD | ||||||||
| FirstName: | WALLENA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GREEN | ||||||||
| OtherFirstName: | WALLENA | ||||||||
| OtherMiddleName: | M | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 650782 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752650782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3027330806 | ||||||||
| FaxNumber: | 3027330854 | ||||||||
| Practice Location | |||||||||
| Address1: | 1505 W SHERMAN AVE | ||||||||
| Address2: | |||||||||
| City: | VINELAND | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 083606912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8566418000 | ||||||||
| FaxNumber: | 8566417668 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 09/05/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 26NJ00243400 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 163W00000X | 26NR08657200 | NJ | N | Nursing Service Providers | Registered Nurse | 367500000X | RN502167L | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 102332049 | 05 | PA | MEDICAID | 072989 | 01 | AANA NUMBER | OTHER | P00795663 | 01 | NJ | RAILROAD MEDICARE | OTHER |