Provider Demographics
NPI:1023687217
Name:WALLACE, MIKAILA (DO)
Entity type:Individual
Prefix:
First Name:MIKAILA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2016 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468-2655
Mailing Address - Country:US
Mailing Address - Phone:660-562-2525
Mailing Address - Fax:660-562-7996
Practice Address - Street 1:2016 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468-2655
Practice Address - Country:US
Practice Address - Phone:660-562-2525
Practice Address - Fax:660-562-7996
Is Sole Proprietor?:No
Enumeration Date:2021-06-22
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024030678207Q00000X
NETEP9082207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200147246Medicaid
NE470553011-00Medicaid