Healthcare Provider Details

I. General information

NPI: 1679021497
Provider Name (Legal Business Name): RYAN JAMES WALLACE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2016
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 GRANGER RD
AKRON OH
44333-1538
US

IV. Provider business mailing address

3535 GRANGER RD
AKRON OH
44333-1538
US

V. Phone/Fax

Practice location:
  • Phone: 330-331-7207
  • Fax: 330-331-7587
Mailing address:
  • Phone: 330-331-7207
  • Fax: 330-331-7587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number25705
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.020062
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: