Provider Demographics
NPI:1679900161
Name:WALLACE, JOHN D
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:WALLACE
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 1:15286 SW 104TH ST APT 2-22
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-3238
Mailing Address - Country:US
Mailing Address - Phone:904-418-3893
Mailing Address - Fax:
Practice Address - Street 1:1455 NW 53RD ST APT 222
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33142
Practice Address - Country:US
Practice Address - Phone:904-418-3893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-30
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
FL235276385H00000X, 376J00000X, 372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No385H00000XRespite Care FacilityRespite Care
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Multi-Specialty