Healthcare Provider Details

I. General information

NPI: 1093460412
Provider Name (Legal Business Name): ALONA WALLACE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2022
Last Update Date: 02/21/2022
Certification Date: 02/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 PINE ST UNIT 216-217
ENGLEWOOD FL
34223-4418
US

IV. Provider business mailing address

1078 EISENHOWER DR
NOKOMIS FL
34275-4411
US

V. Phone/Fax

Practice location:
  • Phone: 941-474-5093
  • Fax:
Mailing address:
  • Phone: 813-451-5701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number11018027
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number11018027
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: