Individual
MRS. JILL MARIE WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
N.P.
Contact information
Practice address
16406 BIRCHLEY CIR, CHARLOTTE, NC 28213-4314
(704) 258-4240
Mailing address
16406 BIRCHLEY CIR, CHARLOTTE, NC 28213-4314
(704) 258-4240
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
19659
SC
363LF0000X
Family Nurse Practitioner
5008608
NC
Other
Enumeration date
01/11/2016
Last updated
09/02/2016
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