Healthcare Provider Details

I. General information

NPI: 1801114905
Provider Name (Legal Business Name): JOANNA MARLISS FUNK NELMS MD, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JOANNA MARLISS FUNK MD

II. Dates (important events)

Enumeration Date: 05/13/2010
Last Update Date: 12/30/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WILFORD HALL AMBULATORY CENTER 1100 WILFORD HALL LOOP
JBSA-LACKLAND AFB TX
78236-4660
US

IV. Provider business mailing address

WILFORD HALL AMBULATORY CENTER 1100 WILFORD HALL LOOP
JBSA-LACKLAND AFB TX
78236-4660
US

V. Phone/Fax

Practice location:
  • Phone: 210-292-3209
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number01070440A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License NumberT4564
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number01070440A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License NumberT4564
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: