Provider Demographics
NPI:1811694540
Name:WALLS CASTELLANOS, MELINIQUE
Entity type:Individual
Prefix:
First Name:MELINIQUE
Middle Name:
Last Name:WALLS CASTELLANOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELINIQUE
Other - Middle Name:
Other - Last Name:WALLS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:733 N BROADWAY STE 137
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21205-1832
Mailing Address - Country:US
Mailing Address - Phone:410-955-3192
Mailing Address - Fax:
Practice Address - Street 1:924 E 57TH ST # 104
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1455
Practice Address - Country:US
Practice Address - Phone:773-702-1937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-13
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program