Healthcare Provider Details

I. General information

NPI: 1396403135
Provider Name (Legal Business Name): LISA LYNN WALLACE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2021
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 PRUDENTIAL DR
JACKSONVILLE FL
32207-8211
US

IV. Provider business mailing address

546 ROCKY CREEK RD
HAMPTON GA
30228-3071
US

V. Phone/Fax

Practice location:
  • Phone: 904-202-8000
  • Fax:
Mailing address:
  • Phone: 678-414-7809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License NumberRN089537
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: