Healthcare Provider Details

I. General information

NPI: 1225357635
Provider Name (Legal Business Name): TERESA M WALLACE APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2010
Last Update Date: 03/07/2023
Certification Date: 03/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1880 OLD HIGHWAY 51 S STE C
BRIGHTON TN
38011-8025
US

IV. Provider business mailing address

PO BOX 1000 DEPT 978
MEMPHIS TN
38148-0001
US

V. Phone/Fax

Practice location:
  • Phone: 901-837-7979
  • Fax: 901-837-7999
Mailing address:
  • Phone: 901-758-9900
  • Fax: 901-752-2335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number14863
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: