Healthcare Provider Details

I. General information

NPI: 1689539801
Provider Name (Legal Business Name): ASHLEE WALLACE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 COUNTY ROAD 143
OXFORD MS
38655-8663
US

IV. Provider business mailing address

152 COUNTY ROAD 143
OXFORD MS
38655-8663
US

V. Phone/Fax

Practice location:
  • Phone: 662-202-7494
  • Fax: 662-202-7494
Mailing address:
  • Phone: 662-202-7494
  • Fax: 662-202-7494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number910290
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: