Provider Demographics
NPI:1255996765
Name:WALBERG, EVELYN D
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:D
Last Name:WALBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 E WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:ELLINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63638-7943
Mailing Address - Country:US
Mailing Address - Phone:573-663-2644
Mailing Address - Fax:
Practice Address - Street 1:315 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:ELLINGTON
Practice Address - State:MO
Practice Address - Zip Code:63638-7943
Practice Address - Country:US
Practice Address - Phone:573-663-2644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO65672146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic