Provider Demographics
NPI:1265437172
Name:WALLIS, JOANNE (ANP)
Entity type:Individual
Prefix:MRS
First Name:JOANNE
Middle Name:
Last Name:WALLIS
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1270 KOT-NUM ROAD
Mailing Address - Street 2:
Mailing Address - City:WARM SPRINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97761-1209
Mailing Address - Country:US
Mailing Address - Phone:541-553-1196
Mailing Address - Fax:541-553-2135
Practice Address - Street 1:1270 KOT-NUM ROAD
Practice Address - Street 2:
Practice Address - City:WARM SPRINGS
Practice Address - State:OR
Practice Address - Zip Code:97761-1209
Practice Address - Country:US
Practice Address - Phone:541-553-1196
Practice Address - Fax:541-553-2135
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK389363LF0000X, 363LW0102X
VA0017139524363LF0000X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health