Provider Demographics
NPI:1740585744
Name:FAVOR WALLICK, JOAN MARIE (BSN)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:MARIE
Last Name:FAVOR WALLICK
Suffix:
Gender:F
Credentials:BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4634 FOX GLEN AVE
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-1836
Mailing Address - Country:US
Mailing Address - Phone:909-599-4328
Mailing Address - Fax:
Practice Address - Street 1:824 N HILL ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-2321
Practice Address - Country:US
Practice Address - Phone:909-762-3606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA376353163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse