Individual
JUSTIN COVEY WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
RN
Contact information
Practice address
4212 N 16TH ST, PHOENIX, AZ 85016-5319
(602) 263-1200
Mailing address
13126 N 154TH AVE, SURPRISE, AZ 85379-9150
Taxonomy
Speciality
Code
Description
License number
State
163WE0003X
Emergency Registered Nurse
Primary
RN173423
AZ
Other
Enumeration date
11/20/2012
Last updated
11/20/2012
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