NPIMap

Organization Active NPI

Walley Clinic PA

  • Family Medicine Physician
  • Waynesboro, MS
National Provider Identifier
1669463584
Registry record updated Feb 27, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
WALLEY CLINIC PA
Practice address
920 Matthew Dr
Ste a
Waynesboro, MS 39367-2567
Phone
(601) 735-2401
Fax
(601) 735-5205
NPI assigned
Oct 31, 2005
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 27, 2008

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

Authorized official

Name
Eletha Jane Jenkins
Title
Ceo
Phone
(601) 735-2401

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X Primary

Addresses

Primary practice location

920 Matthew Dr
Ste a
Waynesboro, MS 39367-2567

Mailing address

920 Matthew Dr
Ste a
Waynesboro, MS 39367-2567
Phone (601) 735-2401

Other identifiers 1

IdentifierTypeStateIssuer
09011779MedicaidMS

National Provider Directory

National Provider Directory

Locations

920 Matthew Dr
Ste A
Waynesboro, MS 39367
Phone (601) 735-2401

920 Matthew Dr
#A
Waynesboro, MS 39367
Phone (601) 735-2401

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1130716800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1204070400000",
    "number": "1669463584",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "920 MATTHEW DR",
            "address_2": "STE A",
            "city": "WAYNESBORO",
            "state": "MS",
            "postal_code": "393672567",
            "telephone_number": "601-735-2401",
            "fax_number": "601-735-5205"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "920 MATTHEW DR",
            "address_2": "STE A",
            "city": "WAYNESBORO",
            "state": "MS",
            "postal_code": "393672567",
            "telephone_number": "601-735-2401",
            "fax_number": "601-735-5205"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WALLEY CLINIC PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-10-31",
        "last_updated": "2008-02-27",
        "status": "A",
        "authorized_official_last_name": "JENKINS",
        "authorized_official_first_name": "ELETHA",
        "authorized_official_middle_name": "JANE",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "601-735-2401"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "09011779",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Waynesboro, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 27, 2008; 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.