Basic Information
| Provider Information | |||||||||
| NPI: | 1619162039 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALSH | ||||||||
| FirstName: | FAITH | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | RNC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1408 19TH AVE | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997015903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074516682 | ||||||||
| FaxNumber: | 9074593976 | ||||||||
| Practice Location | |||||||||
| Address1: | 122 FIRST AVE, SUITE 600 | ||||||||
| Address2: | TANANA CHIEFS CONFERENCE | ||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074528251 | ||||||||
| FaxNumber: | 9074593884 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2007 | ||||||||
| LastUpdateDate: | 09/10/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 20445 | AK | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 0 | 05 | AK | MEDICAID |