Healthcare Provider Details

I. General information

NPI: 1386733863
Provider Name (Legal Business Name): DENISE DESIREE WALLIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 05/20/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9715 LIBERIA AVE
MANASSAS VA
20110-5837
US

IV. Provider business mailing address

6020 RICHMOND HWY STE 102
ALEXANDRIA VA
22303-2157
US

V. Phone/Fax

Practice location:
  • Phone: 571-229-1797
  • Fax: 571-229-1798
Mailing address:
  • Phone: 443-393-3653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101241250
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: