Provider Demographics
NPI:1023620887
Name:WALLEY, PORSCHE ANN (CNA)
Entity type:Individual
Prefix:
First Name:PORSCHE
Middle Name:ANN
Last Name:WALLEY
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5101 ORCHARD AVE APT 91
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39581-3907
Mailing Address - Country:US
Mailing Address - Phone:601-498-1281
Mailing Address - Fax:
Practice Address - Street 1:5101 ORCHARD AVE APT 91
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39581-3907
Practice Address - Country:US
Practice Address - Phone:601-498-1281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-21
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
9892OtherBUSINESS