Provider Demographics
NPI:1568705739
Name:WALLIS, BILLIE M
Entity Type:Individual
Prefix:MR
First Name:BILLIE
Middle Name:M
Last Name:WALLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 NUGGET LN
Mailing Address - Street 2:
Mailing Address - City:TUTTLE
Mailing Address - State:OK
Mailing Address - Zip Code:73089-9213
Mailing Address - Country:US
Mailing Address - Phone:405-381-9140
Mailing Address - Fax:
Practice Address - Street 1:4720 S SHIELDS BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73129-3210
Practice Address - Country:US
Practice Address - Phone:405-632-1976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-05
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management