1235237819 NPI number — MS. JANET ANN WALLACE CNP

Table of content: MS. JANET ANN WALLACE CNP (NPI 1235237819)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235237819 NPI number — MS. JANET ANN WALLACE CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
JANET
Provider Middle Name:
ANN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235237819
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1129 NORRIS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43224-2734
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-262-7758
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1699 W MOUND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43223-1809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-263-5006
Provider Business Practice Location Address Fax Number:
614-263-5019
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  COA 05893 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2305811 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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