Healthcare Provider Details

I. General information

NPI: 1871089680
Provider Name (Legal Business Name): JESSICA RENEE WALLACE APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2018
Last Update Date: 01/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1821 E. HIGH ST.
SPRINGFIELD OH
45505
US

IV. Provider business mailing address

1821 E. HIGH ST.
SPRINGFIELD OH
45505
US

V. Phone/Fax

Practice location:
  • Phone: 937-323-7340
  • Fax: 937-323-3363
Mailing address:
  • Phone: 937-323-7340
  • Fax: 937-323-3363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number021995
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: