Healthcare Provider Details

I. General information

NPI: 1689640195
Provider Name (Legal Business Name): VICKI WALLACE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 02/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 SAM PERRY BLVD., SUITE 211
FREDERICKSBURG VA
22401
US

IV. Provider business mailing address

1101 SAM PERRY BLVD SUITE 211
FREDERICKSBURG VA
22401
US

V. Phone/Fax

Practice location:
  • Phone: 540-372-7792
  • Fax:
Mailing address:
  • Phone: 540-372-7792
  • Fax: 540-372-2073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN67063
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number0024166526
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: