Healthcare Provider Details

I. General information

NPI: 1700769130
Provider Name (Legal Business Name): KRISTEN ELIZABETH WALLACE PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2025
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 L ST NW STE 430
WASHINGTON DC
20001-3615
US

IV. Provider business mailing address

1410 N SCOTT ST APT 1065
ARLINGTON VA
22209-2971
US

V. Phone/Fax

Practice location:
  • Phone: 202-677-3302
  • Fax:
Mailing address:
  • Phone: 214-926-3261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024194511
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: