Provider Demographics
NPI:1699167973
Name:WALLIS, MARINA
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:WALLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13355 N HWY 183 APT 1430
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78750-7141
Mailing Address - Country:US
Mailing Address - Phone:281-777-2462
Mailing Address - Fax:
Practice Address - Street 1:3853 ROSECRANS ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3115
Practice Address - Country:US
Practice Address - Phone:619-692-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-24
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95046963163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health