Healthcare Provider Details

I. General information

NPI: 1558499574
Provider Name (Legal Business Name): JANICE RENEA WALLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 S CHERRY ST
HARRISON AR
72601-5024
US

IV. Provider business mailing address

9476 SUMMIT RD
HARRISON AR
72601-9318
US

V. Phone/Fax

Practice location:
  • Phone: 870-741-0581
  • Fax:
Mailing address:
  • Phone: 870-741-0581
  • Fax: 870-741-8883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberR50350
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: