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General NPI Number Information
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NPI Number | 1023066354
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Entity Type | Individual
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Provider Name | JAMIE RUSSELLE WALLACE MD
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Gender | Female
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Dates
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Enumeration Date | 05/05/2006
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 10752 N 89TH PL #126
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City | SCOTTSDALE
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State | AZ
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Zip | 85260
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Country | US
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Telephone | 480-860-1161
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Fax | 480-860-6561
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Provider Business Mailing Address
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Address Line | 10752 N 89TH PL #126
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City | SCOTTSDALE
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State | AZ
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Zip | 85260
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Country | US
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Telephone | 480-860-1161
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Fax | 480-860-6561
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 12810
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License Number State | AZ
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