Provider Demographics
NPI:1629848502
Name:WALLACE, JUANETTA
Entity Type:Individual
Prefix:
First Name:JUANETTA
Middle Name:
Last Name:WALLACE
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 1:3101 NASA PKWY STE F
Mailing Address - Street 2:
Mailing Address - City:SEABROOK
Mailing Address - State:TX
Mailing Address - Zip Code:77586-6475
Mailing Address - Country:US
Mailing Address - Phone:832-932-5787
Mailing Address - Fax:
Practice Address - Street 1:3101 NASA PKWY STE F
Practice Address - Street 2:
Practice Address - City:SEABROOK
Practice Address - State:TX
Practice Address - Zip Code:77586-6475
Practice Address - Country:US
Practice Address - Phone:832-932-5787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
195708246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant