Individual
JANIKA INEZ WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
D.O.
Contact information
Practice address
104 E CECIL AVE, 1ST FLOOR, NORTH EAST, MD 21901-4016
(410) 287-7021
(410) 287-7067
Mailing address
104 E CECIL AVE, 1ST FLOOR, NORTH EAST, MD 21901-4016
(410) 287-7021
(410) 287-7067
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
25MB09205500
NJ
207Q00000X
Family Medicine Physician
Primary
H0075972
MD
390200000X
Student in an Organized Health Care Education/Training Program
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—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
301409Y2B
MEDICARE
MD
Enumeration date
06/28/2010
Last updated
04/07/2015
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