Healthcare Provider Details

I. General information

NPI: 1235637182
Provider Name (Legal Business Name): LISA M. WALLACE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2018
Last Update Date: 02/24/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E CHEVES ST STE 200
FLORENCE SC
29506-2651
US

IV. Provider business mailing address

PO BOX 3239
FLORENCE SC
29502-3239
US

V. Phone/Fax

Practice location:
  • Phone: 843-662-1502
  • Fax: 843-678-3611
Mailing address:
  • Phone: 843-777-7098
  • Fax: 843-777-7102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number21595
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: