Healthcare Provider Details

I. General information

NPI: 1578428033
Provider Name (Legal Business Name): ROBERT T WALLACE MSN, RN, CNL, AMB-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1865 ELINORA DR
PLEASANT HILL CA
94523-2810
US

IV. Provider business mailing address

1865 ELINORA DR
PLEASANT HILL CA
94523-2810
US

V. Phone/Fax

Practice location:
  • Phone: 925-293-2105
  • Fax:
Mailing address:
  • Phone: 925-293-2105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number95102138
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: