Individual
JEAN A. WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
NP
Contact information
Practice address
300 COMMUNITY DR, MANHASSET, NY 11030-3816
(516) 562-4665
Mailing address
130 ELMWOOD DR, DIX HILLS, NY 11746-5658
(631) 549-1357
Taxonomy
Speciality
Code
Description
License number
State
363LN0000X
Neonatal Nurse Practitioner
Primary
F350149
NY
Other
Enumeration date
06/13/2008
Last updated
06/13/2008
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