Healthcare Provider Details

I. General information

NPI: 1417258294
Provider Name (Legal Business Name): JOETTA DESWARTE WALLCE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2010
Last Update Date: 11/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2653 ELM AVE SUITE 200
LONG BEACH CA
90806-1652
US

IV. Provider business mailing address

6430 W SUNSET BLVD SUITE 600
LOS ANGELES CA
90028-7900
US

V. Phone/Fax

Practice location:
  • Phone: 562-728-5000
  • Fax: 562-595-5296
Mailing address:
  • Phone: 323-361-2337
  • Fax: 323-361-8491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number244499
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number15928
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number787
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: