Healthcare Provider Details

I. General information

NPI: 1790673549
Provider Name (Legal Business Name): JA'MESE B WALLACE DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2025
Last Update Date: 06/27/2025
Certification Date: 06/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3659 S MIAMI AVE STE 3008
MIAMI FL
33133-4225
US

IV. Provider business mailing address

4042 NW 10TH PL
PLANTATION FL
33313-6709
US

V. Phone/Fax

Practice location:
  • Phone: 305-859-7777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberPR909
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: