Healthcare Provider Details

I. General information

NPI: 1396185666
Provider Name (Legal Business Name): AUDREY WALLACE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2013
Last Update Date: 05/16/2025
Certification Date: 05/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 SE 17TH ST
OCALA FL
34471-4118
US

IV. Provider business mailing address

2020 SE 17TH ST
OCALA FL
34471-4118
US

V. Phone/Fax

Practice location:
  • Phone: 352-732-0277
  • Fax:
Mailing address:
  • Phone: 352-732-0277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number33689
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberME136800
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: