Healthcare Provider Details

I. General information

NPI: 1699117119
Provider Name (Legal Business Name): EMILY B WALLACE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2013
Last Update Date: 09/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 PALMETTO HEALTH PKWY
COLUMBIA SC
29212-1760
US

IV. Provider business mailing address

209 TILLMAN ST
LEXINGTON SC
29072-7536
US

V. Phone/Fax

Practice location:
  • Phone: 800-907-7000
  • Fax:
Mailing address:
  • Phone: 704-245-2890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0001246344
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number100969
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number24736
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: