Provider Demographics
NPI:1700068020
Name:WALLACE, MOLLEE JOHANSEN (PA-C)
Entity type:Individual
Prefix:MS
First Name:MOLLEE
Middle Name:JOHANSEN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3537 S I 35 E STE 320B
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76210-6800
Mailing Address - Country:US
Mailing Address - Phone:214-851-1777
Mailing Address - Fax:855-576-4130
Practice Address - Street 1:3537 S INTERSTATE 35 E
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76210-6800
Practice Address - Country:US
Practice Address - Phone:214-851-1777
Practice Address - Fax:855-576-4130
Is Sole Proprietor?:No
Enumeration Date:2007-11-28
Last Update Date:2025-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02519363A00000X
TXPA02159363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA02519OtherLICENSE