Provider Demographics
NPI:1760589394
Name:WALLIE, MARISSA I (DC)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:I
Last Name:WALLIE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 BRENWOODE RD
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21409-5494
Mailing Address - Country:US
Mailing Address - Phone:410-757-3413
Mailing Address - Fax:410-349-4605
Practice Address - Street 1:530 COLLEGE PKWY
Practice Address - Street 2:SUITE F
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21409-4614
Practice Address - Country:US
Practice Address - Phone:410-349-2727
Practice Address - Fax:410-349-4605
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01998111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor