MEDICARE: MRS. JILL MARIE WALLACE N.P.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	19659	SC
2	363LF0000X	Family Nurse Practitioner	5008608	NC

General Provider Information

NPI Number	:	1598121220
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JILL MARIE WALLACE N.P.

Provider Business Mailing Address
First Line	:	16406 BIRCHLEY CIR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28213-4314
Country	:	US
Telephone Number	:	704-258-4240
Fax Number	:

Provider Business Practice Location Address
First Line	:	16406 BIRCHLEY CIR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28213-4314
Country	:	US
Telephone Number	:	704-258-4240
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2016
Last Update Date	:	09/02/2016

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