Provider Demographics
NPI:1871706978
Name:BALIEM, WILMA DIANE (CRNP)
Entity type:Individual
Prefix:
First Name:WILMA
Middle Name:DIANE
Last Name:BALIEM
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40430
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36640-0430
Mailing Address - Country:US
Mailing Address - Phone:251-665-8000
Mailing Address - Fax:251-665-8010
Practice Address - Street 1:1660 SPRINGHILL AVENUE
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36640-0430
Practice Address - Country:US
Practice Address - Phone:251-665-8000
Practice Address - Fax:251-665-8010
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-046774363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051544202OtherBCBS - 1660 SPRINGHILL AVE
AL51542600OtherBCBS - HSF
AL891017418Medicaid
FL308566000Medicaid
MS00985524Medicaid
AL51542600OtherBCBS - HSF