Provider Demographics
NPI:1023515327
Name:WALLEN, ASHLEY BROOKE (PA-C)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:BROOKE
Last Name:WALLEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3597 W CHERRY RD
Mailing Address - Street 2:
Mailing Address - City:PICKRELL
Mailing Address - State:NE
Mailing Address - Zip Code:68422-8091
Mailing Address - Country:US
Mailing Address - Phone:402-239-2775
Mailing Address - Fax:
Practice Address - Street 1:11819 MIRACLE HILLS DR STE 105
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-4428
Practice Address - Country:US
Practice Address - Phone:402-905-2075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2228363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant