Healthcare Provider Details

I. General information

NPI: 1093988933
Provider Name (Legal Business Name): TONIALATOYA WALLACE-ELEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TONIALATOYA WALLACE

II. Dates (important events)

Enumeration Date: 04/11/2008
Last Update Date: 11/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6201 N SUNCOAST BLVD
CRYSTAL RIVER FL
34428-6712
US

IV. Provider business mailing address

PO BOX 2030
HOMOSASSA SPRINGS FL
34447-2030
US

V. Phone/Fax

Practice location:
  • Phone: 352-795-6560
  • Fax: 770-776-5966
Mailing address:
  • Phone: 352-621-3100
  • Fax: 352-621-3121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number4301089191
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: