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General NPI Number Information
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NPI Number | 1699122820
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Entity Type | Individual
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Provider Name | JENA WALLACE
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Gender | Female
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Dates
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Enumeration Date | 05/17/2016
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Last Update Date | 03/17/2021
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Provider Practice Location Address
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Address Line | 322 MULBERRY ST SW STE A
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City | LENOIR
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State | NC
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Zip | 28645-5703
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Country | US
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Telephone | 828-757-6460
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Fax | 828-759-4901
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Provider Business Mailing Address
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Address Line | 1853 18TH STREET CT NE
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City | HICKORY
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State | NC
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Zip | 28601-0533
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Country | US
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Telephone | 860-334-2475
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 253837
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License Number State | NC
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