Individual
JACQUELINE M WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PHYSICIAN
Contact information
Practice address
10910 LITTLE PATUXENT PKWY, SUITE 100, COLUMBIA, MD 21044-3078
(410) 997-8444
Mailing address
10910 LITTLE PATUXENT PKWY, SUITE 100, COLUMBIA, MD 21044-3078
(410) 997-8444
Taxonomy
Speciality
Code
Description
License number
State
207V00000X
Obstetrics & Gynecology Physician
Primary
D0069282
MD
207V00000X
Obstetrics & Gynecology Physician
MD059921L
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
101044156
—
PA
Enumeration date
06/02/2006
Last updated
06/22/2010
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