Provider Demographics
NPI:1316800345
Name:WALLACE, JOHNNY LEE JR
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:LEE
Last Name:WALLACE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1000
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93302-1000
Mailing Address - Country:US
Mailing Address - Phone:760-379-3412
Mailing Address - Fax:
Practice Address - Street 1:3401 WIBLE RD APT 91
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93309-6536
Practice Address - Country:US
Practice Address - Phone:760-379-3412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-12-05
Last Update Date:2025-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker