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General NPI Number Information
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NPI Number | 1417642364
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Entity Type | Individual
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Provider Name | JONELLE WALLACE APRN, NP-C
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Gender | Female
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Dates
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Enumeration Date | 04/06/2023
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Last Update Date | 04/06/2023
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Provider Practice Location Address
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Address Line | 10175 LITTLE PATUXENT PKWY
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City | COLUMBIA
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State | MD
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Zip | 21044-2655
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Country | US
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Telephone | 800-328-5979
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1459
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City | MINNEAPOLIS
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State | MN
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Zip | 55440-1459
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Country | US
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Telephone |
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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 | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 11314
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License Number State | CT
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