Healthcare Provider Details

I. General information

NPI: 1023937711
Provider Name (Legal Business Name): PRESLEY WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 MACCORKLE AVE SE
CHARLESTON WV
25304-1227
US

IV. Provider business mailing address

1819 MARTINS BRANCH RD
CHARLESTON WV
25312-5607
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-5432
  • Fax:
Mailing address:
  • Phone: 304-543-2092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number112878
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: