Individual
JAILENE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
FNP-C
Contact information
Practice address
712 BROAD ST, PROVIDENCE, RI 02907-1465
(401) 233-5060
Mailing address
PO BOX 746088, ATLANTA, GA 30374-6088
Taxonomy
Speciality
Code
Description
License number
State
207QG0300X
Geriatric Medicine (Family Medicine) Physician
APRN04646
RI
363LF0000X
Family Nurse Practitioner
Primary
APRN04646
RI
Other
Enumeration date
07/29/2025
Last updated
09/15/2025
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