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General NPI Number Information
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NPI Number | 1013886456
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Entity Type | Individual
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Provider Name | CHERRY WALLACE
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Gender | Female
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Dates
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Enumeration Date | 11/03/2025
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Last Update Date | 11/04/2025
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Provider Practice Location Address
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Address Line | 425 N NEW BALLAS RD STE 203
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City | SAINT LOUIS
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State | MO
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Zip | 63141-6848
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Country | US
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Telephone | 314-872-3104
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Fax |
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Provider Business Mailing Address
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Address Line | 905 CHESTNUT RIDGE RD
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City | MANCHESTER
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State | MO
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Zip | 63021-6925
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Country | US
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Telephone | 314-536-1897
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Fax | 314-536-1897
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 2025047590
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License Number State | MO
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