Healthcare Provider Details

I. General information

NPI: 1861989279
Provider Name (Legal Business Name): DANA MARIE WALLACE CRNP FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2018
Last Update Date: 04/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5040 CITY AVE
PHILADELPHIA PA
19131-1435
US

IV. Provider business mailing address

25 DUDLEY AVE
LANSDOWNE PA
19050-2802
US

V. Phone/Fax

Practice location:
  • Phone: 215-877-2116
  • Fax:
Mailing address:
  • Phone: 484-477-5063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP018488
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: