Provider Demographics
NPI:1669578548
Name:WALLICK, JANINE ELISE (NP)
Entity type:Individual
Prefix:
First Name:JANINE
Middle Name:ELISE
Last Name:WALLICK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Mailing Address - Street 1:8805 N MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2760
Mailing Address - Country:US
Mailing Address - Phone:317-706-7246
Mailing Address - Fax:317-706-3419
Practice Address - Street 1:533 E COUNTY LINE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1073
Practice Address - Country:US
Practice Address - Phone:317-706-7246
Practice Address - Fax:317-706-3417
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2016-09-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN71001045A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200368100Medicaid