Myrna Rae Van de Walle, PHYSICAL THERAPIST

Primary specialty

Physical TherapistTaxonomy code 225100000X

License

00694 Issued in IA

Practice address

9184 265TH St
Suite B
Clear Lake, IA 50428-8507

Phone

(641) 357-6112

Fax

(641) 357-3686

NPI assigned

Jan 26, 2007

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1169769600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1083760755",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "609 S TENNESSEE PL",
            "city": "MASON CITY",
            "state": "IA",
            "postal_code": "504015358",
            "telephone_number": "641-424-6042"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9184 265TH ST",
            "address_2": "SUITE B",
            "city": "CLEAR LAKE",
            "state": "IA",
            "postal_code": "504288507",
            "telephone_number": "641-357-6112",
            "fax_number": "641-357-3686"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "VAN DE WALLE",
        "first_name": "MYRNA",
        "middle_name": "RAE",
        "name_prefix": "Mrs.",
        "credential": "PHYSICAL THERAPIST",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2007-01-26",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "IA",
            "license": "00694",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Physical Therapist in Clear Lake, IA
• Providers in Clear Lake, IA by specialty
• Physical Therapist in Iowa

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.