Healthcare Provider Details

I. General information

NPI: 1427058932
Provider Name (Legal Business Name): EVELINE S. WALLACE ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 11/11/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 N ORANGE AVE SUITE # 700
ORLANDO FL
32804-5505
US

IV. Provider business mailing address

2415 N ORANGE AVE SUITE # 700
ORLANDO FL
32804-5505
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-7171
  • Fax: 407-303-7195
Mailing address:
  • Phone: 407-303-7171
  • Fax: 407-303-7195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number1728202
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: