Doctor Name: | JANIKA INEZ WALLACE |
NPI Number: | 1255642930 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | D.O. |
License Number: | |
Business Practice Address: | 104 E Cecil Ave 1st Floor North East, MD - 219014016 |
Business Phone Number: | 4102877021 |
Business Fax Number: | 4102877067 |
Mailing Address: | 104 E Cecil Ave, 1st Floor NORTH EAST |
State: | MD |
Postal Code: | 219014016 |
Phone Number: | 4102877021 |
Fax Number: | 4102877067 |
NPI Enumeration Date: | 06/28/2010 |
NPI Last Update Date: | 04/07/2015 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 390200000X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | N |
State: | |
Taxonomy Type: | Student, Health Care |
Taxonomy Classification: | Student in an Organized Health Care Education/Training Program |
Taxonomy Specialization: | |
Taxonomy Definition: | An individual who is enrolled in an organized health care education/training program leading to a degree, certification, registration, and/or licensure to provide health care. |