Basic Information
| Provider Information | |||||||||
| NPI: | 1417258294 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLCE | ||||||||
| FirstName: | JOETTA | ||||||||
| MiddleName: | DESWARTE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6430 W SUNSET BLVD | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900287900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233612337 | ||||||||
| FaxNumber: | 3233618491 | ||||||||
| Practice Location | |||||||||
| Address1: | 2653 ELM AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908061652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5627285000 | ||||||||
| FaxNumber: | 5625955296 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2010 | ||||||||
| LastUpdateDate: | 11/09/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 244499 | CA | N | Nursing Service Providers | Registered Nurse | 363L00000X | 15928 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 364S00000X | 787 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist |
No ID Information.