Provider Demographics
NPI:1932370756
Name:WALLIS, JOANNE M (PNP)
Entity Type:Individual
Prefix:
First Name:JOANNE
Middle Name:M
Last Name:WALLIS
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:M
Other - Last Name:WALLIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PNP
Mailing Address - Street 1:426 SW STARK ST FL 9
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-2347
Mailing Address - Country:US
Mailing Address - Phone:503-988-5958
Mailing Address - Fax:503-988-4093
Practice Address - Street 1:19005 SE 34TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-1450
Practice Address - Country:US
Practice Address - Phone:360-726-6724
Practice Address - Fax:360-726-6718
Is Sole Proprietor?:No
Enumeration Date:2008-03-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR091000332N2-PNP-PP363LP0200X
WAAP30006123363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022959Medicaid
OR22959Medicaid
P49225Medicare UPIN
OR22959Medicaid