Provider Demographics
NPI:1417258294
Name:WALLCE, JOETTA DESWARTE (NP)
Entity Type:Individual
Prefix:
First Name:JOETTA
Middle Name:DESWARTE
Last Name:WALLCE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6430 W SUNSET BLVD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-7900
Mailing Address - Country:US
Mailing Address - Phone:323-361-2337
Mailing Address - Fax:323-361-8491
Practice Address - Street 1:2653 ELM AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-1652
Practice Address - Country:US
Practice Address - Phone:562-728-5000
Practice Address - Fax:562-595-5296
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-09
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA244499163W00000X
CA15928363L00000X
CA787364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist