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General NPI Number Information
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NPI Number | 1356558324
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Entity Type | Individual
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Provider Name | JUDY LYNN WALLIS PTA
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Gender | Female
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Dates
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Enumeration Date | 05/17/2007
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Last Update Date | 12/07/2018
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Provider Practice Location Address
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Address Line | MARYWOOD HEALTH CENTER 111 LAKESIDE DRIVE NE
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City | GRAND RAPIDS
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State | MI
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Zip | 49503
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Country | US
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Telephone | 616-453-7715
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Fax |
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Provider Business Mailing Address
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Address Line | 8572 MCARTHUR AVE NE
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City | GREENVILLE
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State | MI
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Zip | 48838-8372
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Country | US
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Telephone | 616-481-4235
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Fax |
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 5502000688
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number |
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License Number State |
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