Marquita Diane Wallace

Primary specialty

DentistTaxonomy code 122300000X

License

6135 Issued in LA

Practice address

600 N Highway 190
Suite 4
Covington, LA 70433-5003

Phone

(615) 887-1379

NPI assigned

Feb 26, 2010

Sex

Female

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in LA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

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

{
    "created_epoch": "1267142400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1380067200000",
    "number": "1598087900",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "600 N HIGHWAY 190",
            "address_2": "SUITE 4",
            "city": "COVINGTON",
            "state": "LA",
            "postal_code": "704335003",
            "telephone_number": "615-887-1379"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "600 N HIGHWAY 190",
            "address_2": "SUITE 4",
            "city": "COVINGTON",
            "state": "LA",
            "postal_code": "704335003",
            "telephone_number": "615-887-1379"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "MARQUITA",
        "middle_name": "DIANE",
        "name_prefix": "Ms.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2010-02-26",
        "last_updated": "2013-09-25",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "LA",
            "license": "6135",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Jennifer Walkenford, LAC-CCS, NCC
• Kassidy B Wall, FNP
• Anne Marie Wallace, LPC
• Huong Tran Wallace, FNP-C
• Kirsten N Wallace, N/A
• Joshua K Walls, MD
• Michael E Walsh, MD
• Geneal Poynter Walters, CCC-SLP
• Tamu A Walters, CAC
• Teresita M. Walters, BCBA, LBA

• Dentist in Covington, LA
• Providers in Covington, LA by specialty
• Dentist in Louisiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 25, 2013; 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.