Healthcare Provider Details

I. General information

NPI: 1912047564
Provider Name (Legal Business Name): SHERRIE DAWN RUBIO-WALLACE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 03/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1252 N 22ND ST UNIT A
LARAMIE WY
82072-5306
US

IV. Provider business mailing address

2161 N 17TH ST
LARAMIE WY
82072-1912
US

V. Phone/Fax

Practice location:
  • Phone: 307-745-5364
  • Fax: 307-745-4164
Mailing address:
  • Phone: 307-742-4054
  • Fax: 307-766-4294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number18783.0221
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: