Healthcare Provider Details

I. General information

NPI: 1215829528
Provider Name (Legal Business Name): JULIE WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2025
Last Update Date: 07/21/2025
Certification Date: 07/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 E 125TH TER
KANSAS CITY MO
64145-1659
US

IV. Provider business mailing address

501 E 108TH TER
KANSAS CITY MO
64131-4019
US

V. Phone/Fax

Practice location:
  • Phone: 816-797-9810
  • Fax:
Mailing address:
  • Phone: 816-309-0578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: