Healthcare Provider Details

I. General information

NPI: 1811393648
Provider Name (Legal Business Name): CYNTHIA WALLACE AGPCNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2014
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 CRATER LAKE AVE
MEDFORD OR
97504-6241
US

IV. Provider business mailing address

PO BOX 3308
PORTLAND OR
97208-3308
US

V. Phone/Fax

Practice location:
  • Phone: 541-732-5250
  • Fax: 541-732-5251
Mailing address:
  • Phone: 541-732-5250
  • Fax: 541-732-5152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number201500016NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: