Individual
MIKAILA WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DO
Contact information
Practice address
2016 S MAIN ST, MARYVILLE, MO 64468-2655
(660) 562-2525
(660) 562-7996
Mailing address
2016 S MAIN ST, MARYVILLE, MO 64468-2655
(660) 562-2525
(660) 562-7996
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
2024030678
MO
207Q00000X
Family Medicine Physician
TEP9082
NE
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200147246
—
MO
05
—
470553011-00
—
NE
Enumeration date
06/22/2021
Last updated
05/12/2025
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