Healthcare Provider Details

I. General information

NPI: 1710645866
Provider Name (Legal Business Name): SUSANNAH WALLACE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2021
Last Update Date: 03/27/2025
Certification Date: 03/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 MISSION ST
SAN FRANCISCO CA
94103-2513
US

IV. Provider business mailing address

1449 FAIRBANKS ST SW
ATLANTA GA
30310-4349
US

V. Phone/Fax

Practice location:
  • Phone: 646-650-5337
  • Fax: 646-871-6820
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number95029800
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: