Healthcare Provider Details

I. General information

NPI: 1205222619
Provider Name (Legal Business Name): EVA ANNMAE WALLACE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2015
Last Update Date: 04/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1539 NE 22ND AVE SUITE A
OCALA FL
34470-4761
US

IV. Provider business mailing address

1539 NE 22ND AVE SUITE A
OCALA FL
34470-4761
US

V. Phone/Fax

Practice location:
  • Phone: 352-369-7860
  • Fax:
Mailing address:
  • Phone: 352-369-7860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberRN9208381
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: