Healthcare Provider Details

I. General information

NPI: 1144633991
Provider Name (Legal Business Name): JOANNE WALLACE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2014
Last Update Date: 06/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 DEARING DR
SHEPHERD MI
48883-8000
US

IV. Provider business mailing address

121 DEARING DR
SHEPHERD MI
48883-8000
US

V. Phone/Fax

Practice location:
  • Phone: 989-430-5772
  • Fax:
Mailing address:
  • Phone: 989-430-5772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704266337
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: