Amy Jo Wallace, MD

Primary specialty

Pediatrics PhysicianTaxonomy code 208000000X

License

200600865 Issued in NC

Practice address

861 Old Winston Rd Ste 101
Kernersville, NC 27284-7141

Phone

(336) 904-0143

Fax

(336) 904-0046

NPI assigned

Jul 11, 2006

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in NC

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: awallace2754935@carolinashealthcaresystem.direct-ci.com

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Wake Forest Health Network LLC

  • Pediatrics Physician
  • Greensboro, NC
  • NPI 1477785756
  Medicare reassignment NPD
• Wake Forest University Health Sciences

  • Multi-Specialty Clinic/Center
  • Winston Salem, NC
  • NPI 1003803032
  Medicare reassignment NPD
• Cornerstone Health Care, LLC

  • Psychologist
  • High Point, NC
  • NPI 1376890202
  NPD
• Wake Forest Health Network, LLC

  • Pediatrics Physician
  • Greensboro, NC
  • NPI 1053175299
  NPD
• Cornerstone Health Care LLC

  • Clinical Medical Laboratory
  • Conover, NC
  • NPI 1871159145
  NPD (past)
• Wake Forest Health Network LLC

  • Family Medicine Physician
  • Granite Falls, NC
  • NPI 1770858938
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1152576000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1604448000000",
    "number": "1467487322",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 602658",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282602658",
            "telephone_number": "336-716-2011"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "861 OLD WINSTON RD STE 101",
            "city": "KERNERSVILLE",
            "state": "NC",
            "postal_code": "272847141",
            "telephone_number": "336-904-0143",
            "fax_number": "336-904-0046"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "815 Old Winston Rd",
            "address_purpose": "LOCATION",
            "city": "Kernersville",
            "state": "NC",
            "postal_code": "272847124",
            "country_code": "US",
            "telephone_number": "336-713-0990",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "AMY JO",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-07-11",
        "last_updated": "2020-11-04",
        "certification_date": "2020-11-04",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "SC",
            "license": "26169",
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "NC",
            "license": "200600865",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Jessica Mariko Walker
• Kari Tate Walker, FNP-C
• Kevin Bradford Walker, PA-C
• Veronica Siafacas Walker, D.D.S.
• Zachary Walker, DDS
• Diamond Wallace
• Kelley Annette Wallace, DO
• Thomas Raymond Walsh, MD
• Martha Walters, LPN
• Qianyun Wang, MD

• Pediatrics Physician in Kernersville, NC
• Providers in Kernersville, NC by specialty
• Pediatrics Physician in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 4, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.