Healthcare Provider Details

I. General information

NPI: 1255642930
Provider Name (Legal Business Name): JANIKA INEZ WALLACE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2010
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 TOWER LN STE 100
MIDDLETOWN DE
19709-1763
US

IV. Provider business mailing address

601 TOWER LN STE 100
MIDDLETOWN DE
19709-1763
US

V. Phone/Fax

Practice location:
  • Phone: 302-374-0308
  • Fax: 302-204-6306
Mailing address:
  • Phone: 302-374-0308
  • Fax: 302-204-6306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC2-0013228
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberH0075972
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB09205500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: