Healthcare Provider Details

I. General information

NPI: 1568911675
Provider Name (Legal Business Name): CHRISTINA ANN WALLACE CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHRISTINA ANN MORMILE CNP

II. Dates (important events)

Enumeration Date: 09/30/2016
Last Update Date: 03/18/2022
Certification Date: 03/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1144 DUBLIN RD
COLUMBUS OH
43215-1039
US

IV. Provider business mailing address

9293 STATE ROUTE 43 SUITE B
STREETSBORO OH
44241-5374
US

V. Phone/Fax

Practice location:
  • Phone: 614-234-0200
  • Fax: 614-234-0201
Mailing address:
  • Phone: 330-626-1113
  • Fax: 330-626-1133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPRN.CNP.019939
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: