Healthcare Provider Details

I. General information

NPI: 1205258258
Provider Name (Legal Business Name): KYLE WALLACE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2014
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2015 GRAND CONCOURSE
BRONX NY
10453-4303
US

IV. Provider business mailing address

2626 HALPERIN AVE
BRONX NY
10461-2631
US

V. Phone/Fax

Practice location:
  • Phone: 718-583-7736
  • Fax: 718-537-6180
Mailing address:
  • Phone: 718-618-0401
  • Fax: 347-479-1303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number546269-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF311097-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: