Healthcare Provider Details

I. General information

NPI: 1871906909
Provider Name (Legal Business Name): BETH IRENE WALLACE FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BETH IRENE SPINK

II. Dates (important events)

Enumeration Date: 06/05/2014
Last Update Date: 05/15/2022
Certification Date: 05/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4354 NW 23RD AVE # AVW
GAINESVILLE FL
32606-6541
US

IV. Provider business mailing address

4354 NW 23RD AVE # AVW
GAINESVILLE FL
32606-6541
US

V. Phone/Fax

Practice location:
  • Phone: 352-376-4565
  • Fax:
Mailing address:
  • Phone: 352-376-4565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP 9399487
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: