Provider Demographics
NPI:1144606195
Name:WALLACE, JAMI MICHELLE (APN)
Entity Type:Individual
Prefix:
First Name:JAMI
Middle Name:MICHELLE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3591 GRIFFIN AVE
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-6258
Mailing Address - Country:US
Mailing Address - Phone:309-353-6301
Mailing Address - Fax:
Practice Address - Street 1:3591 GRIFFIN AVE
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-6258
Practice Address - Country:US
Practice Address - Phone:309-353-6301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-31
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209012991363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily