Healthcare Provider Details

I. General information

NPI: 1982993366
Provider Name (Legal Business Name): TEREASA ANNE WALLACE RN, MN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2011
Last Update Date: 04/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1333 IRIS AVE
BOULDER CO
80304-2226
US

IV. Provider business mailing address

1333 IRIS AVE
BOULDER CO
80304-2226
US

V. Phone/Fax

Practice location:
  • Phone: 303-443-8500
  • Fax: 720-406-3664
Mailing address:
  • Phone: 720-562-0566
  • Fax: 720-406-3664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number92415
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: