Healthcare Provider Details

I. General information

NPI: 1891288742
Provider Name (Legal Business Name): CARIN LYNNAE WALLACE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2018
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5985 SILVER FALLS RUN STE 100
BRADENTON FL
34211-1291
US

IV. Provider business mailing address

PO BOX 748817
ATLANTA GA
30374-8817
US

V. Phone/Fax

Practice location:
  • Phone: 941-202-2055
  • Fax: 877-550-1635
Mailing address:
  • Phone: 813-286-0033
  • Fax: 813-282-1806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP137578
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF04180557
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: