Healthcare Provider Details

I. General information

NPI: 1467429860
Provider Name (Legal Business Name): WILLIAM S WALLACE APNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2006
Last Update Date: 06/13/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 GATEWAY CT
WEST BEND WI
53095-8539
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 262-335-8600
  • Fax:
Mailing address:
  • Phone: 800-326-2250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberKS44943
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2475
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: