Healthcare Provider Details

I. General information

NPI: 1669578548
Provider Name (Legal Business Name): JANINE ELISE WALLICK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

533 E COUNTY LINE RD SUITE 201
GREENWOOD IN
46143-1073
US

IV. Provider business mailing address

8805 N MERIDIAN ST
INDIANAPOLIS IN
46260-2760
US

V. Phone/Fax

Practice location:
  • Phone: 317-706-7246
  • Fax: 317-706-3417
Mailing address:
  • Phone: 317-706-7246
  • Fax: 317-706-3419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number71001045A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: