Healthcare Provider Details

I. General information

NPI: 1356558324
Provider Name (Legal Business Name): JUDY LYNN WALLIS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 12/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MARYWOOD HEALTH CENTER 111 LAKESIDE DRIVE NE
GRAND RAPIDS MI
49503
US

IV. Provider business mailing address

8572 MCARTHUR AVE NE
GREENVILLE MI
48838-8372
US

V. Phone/Fax

Practice location:
  • Phone: 616-453-7715
  • Fax:
Mailing address:
  • Phone: 616-481-4235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502000688
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: