Healthcare Provider Details

I. General information

NPI: 1497729909
Provider Name (Legal Business Name): NICHOLE G WALLACE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUZANNE NICHOLE GREEN MD

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 12/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13123 E 16TH AVE B390
AURORA CO
80045-7106
US

IV. Provider business mailing address

PO BOX 110429
AURORA CO
80042-0429
US

V. Phone/Fax

Practice location:
  • Phone: 303-864-5250
  • Fax:
Mailing address:
  • Phone: 303-493-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080C0008X
TaxonomyChild Abuse Pediatrics Physician
License NumberDR0054149
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier200020480B
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: