Provider Demographics
NPI:1386733863
Name:WALLIS, DENISE DESIREE (MD)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:DESIREE
Last Name:WALLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6020 RICHMOND HWY
Mailing Address - Street 2:STE 102
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22303-2157
Mailing Address - Country:US
Mailing Address - Phone:443-393-3653
Mailing Address - Fax:
Practice Address - Street 1:9715 LIBERIA AVE
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-5837
Practice Address - Country:US
Practice Address - Phone:571-229-1797
Practice Address - Fax:571-229-1798
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101241250207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA020937YWAU - 321847Medicare PIN
VAVV9104A - C03895Medicare PIN