Healthcare Provider Details

I. General information

NPI: 1700531498
Provider Name (Legal Business Name): TONIA WALLACE PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2022
Last Update Date: 08/15/2026
Certification Date: 08/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2818 QUEEN CITY DR STE E
CHARLOTTE NC
28208-2736
US

IV. Provider business mailing address

205 N MICHIGAN AVE STE 810
CHICAGO IL
60601-5902
US

V. Phone/Fax

Practice location:
  • Phone: 623-294-8804
  • Fax:
Mailing address:
  • Phone: 623-294-8804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5020892
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number270985
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: