Individual
MARY MICHELLE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
N.P.
Contact information
Practice address
444 N 44TH ST, #200, PHOENIX, AZ 85008-7624
(602) 685-3846
(602) 685-3808
Mailing address
444 N 44TH ST, #200, PHOENIX, AZ 85008-7624
(602) 685-3846
(602) 685-3808
Taxonomy
Speciality
Code
Description
License number
State
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
RN030118
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
637184
—
AZ
Enumeration date
04/25/2007
Last updated
07/08/2007
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