Healthcare Provider Details

I. General information

NPI: 1396736997
Provider Name (Legal Business Name): TASHA B WALLACE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14651 PALM BEACH BLVD STE 100
FORT MYERS FL
33905-2331
US

IV. Provider business mailing address

14651 PALM BEACH BLVD STE 100
FORT MYERS FL
33905-2331
US

V. Phone/Fax

Practice location:
  • Phone: 239-369-2903
  • Fax: 239-369-0500
Mailing address:
  • Phone: 239-369-2903
  • Fax: 239-369-0500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS8622
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: