Healthcare Provider Details

I. General information

NPI: 1063085116
Provider Name (Legal Business Name): EVELYN WALLACE REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2021
Last Update Date: 07/16/2021
Certification Date: 07/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2204 E DEBORAH LN
ORANGE CA
92869-4620
US

IV. Provider business mailing address

2906 E HOOVER AVE
ORANGE CA
92867-6253
US

V. Phone/Fax

Practice location:
  • Phone: 714-336-3712
  • Fax:
Mailing address:
  • Phone: 714-639-1465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number300613124
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: