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General NPI Number Information
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NPI Number | 1932370756
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Entity Type | Individual
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Provider Name | JOANNE M WALLIS PNP
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Gender | Female
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Dates
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Enumeration Date | 03/19/2008
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Last Update Date | 03/17/2018
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Provider Practice Location Address
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Address Line | 19005 SE 34TH ST
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City | VANCOUVER
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State | WA
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Zip | 98683-1450
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Country | US
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Telephone | 360-726-6724
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Fax | 360-726-6718
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Provider Business Mailing Address
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Address Line | 426 SW STARK ST FL 9
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City | PORTLAND
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State | OR
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Zip | 97204-2347
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Country | US
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Telephone | 503-988-5958
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Fax | 503-988-4093
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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 | 363LP0200X
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Taxonomy Name | Pediatric Nurse Practitioner
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License Number | 091000332N2-PNP-PP
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number | AP30006123
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License Number State | WA
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