Healthcare Provider Details

I. General information

NPI: 1255290466
Provider Name (Legal Business Name): CAMILLE WALLACE NURSE PRACTITIONER IN FAMILY HEALTH SERVICES, PLLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2026
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 RINGTOP RD
KINGSTON NY
12401-6155
US

IV. Provider business mailing address

8 N FRONT ST # 1002
KINGSTON NY
12401-3814
US

V. Phone/Fax

Practice location:
  • Phone: 845-489-1073
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CAMILLE ANNE WALLACE
Title or Position: OWNER
Credential: NP
Phone: 845-489-1073