Provider Demographics
NPI:1235237819
Name:WALLACE, JANET ANN (CNP)
Entity Type:Individual
Prefix:MS
First Name:JANET
Middle Name:ANN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 NORRIS DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43224-2734
Mailing Address - Country:US
Mailing Address - Phone:614-262-7758
Mailing Address - Fax:
Practice Address - Street 1:1699 W MOUND ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43223-1809
Practice Address - Country:US
Practice Address - Phone:614-263-5006
Practice Address - Fax:614-263-5019
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA 05893363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2305811Medicaid
WANP09501Medicare ID - Type Unspecified
P47464Medicare UPIN