MEDICARE: TAMYRA WALLACE FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	AP135378	TX
2	363LF0000X	Family Nurse Practitioner	AP135378	TN

General Provider Information

NPI Number	:	1952818403
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMYRA WALLACE FNP

Provider Business Mailing Address
First Line	:	8189 MIDTOWN BLVD APT 12217
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75231-4561
Country	:	US
Telephone Number	:	337-201-1875
Fax Number	:

Provider Business Practice Location Address
First Line	:	8189 MIDTOWN BLVD APT 12217
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75231
Country	:	US
Telephone Number	:	337-201-1875
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/05/2018
Last Update Date	:	07/03/2018

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