Healthcare Provider Details

I. General information

NPI: 1558256594
Provider Name (Legal Business Name): TRENEICE WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2025
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7487 S STATE ROAD 121 # A
MACCLENNY FL
32063-5451
US

IV. Provider business mailing address

14511 MACADAMIA LN
JACKSONVILLE FL
32218-1980
US

V. Phone/Fax

Practice location:
  • Phone: 904-330-2572
  • Fax:
Mailing address:
  • Phone: 954-607-8406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number9176588
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: