Provider Demographics
NPI:1689827891
Name:WALLACE, JOEL NIELSON (RNFA)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:NIELSON
Last Name:WALLACE
Suffix:
Gender:M
Credentials:RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9354 PUMICE LN
Mailing Address - Street 2:
Mailing Address - City:CENTRAL POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97502-9325
Mailing Address - Country:US
Mailing Address - Phone:541-826-7209
Mailing Address - Fax:541-779-4824
Practice Address - Street 1:9354 PUMICE LN
Practice Address - Street 2:
Practice Address - City:CENTRAL POINT
Practice Address - State:OR
Practice Address - Zip Code:97502-9325
Practice Address - Country:US
Practice Address - Phone:541-826-7209
Practice Address - Fax:541-779-4824
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-31
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR086006227RN163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant