Provider Demographics
NPI:1558499574
Name:WALLIS, JANICE RENEA
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:RENEA
Last Name:WALLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9476 SUMMIT RD
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72601-9318
Mailing Address - Country:US
Mailing Address - Phone:870-741-0581
Mailing Address - Fax:870-741-8883
Practice Address - Street 1:110 S CHERRY ST
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-5024
Practice Address - Country:US
Practice Address - Phone:870-741-0581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR50350163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool