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General NPI Number Information
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NPI Number | 1124342563
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Entity Type | Individual
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Provider Name | CASSANDRA ANN WALLACE-WICAL ARNP
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Gender | Female
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Dates
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Enumeration Date | 03/14/2010
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Last Update Date | 02/06/2023
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Provider Practice Location Address
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Address Line | 2350 SUNSET POINT RD STE C
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City | CLEARWATER
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State | FL
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Zip | 33765-1443
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Country | US
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Telephone | 727-797-3155
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Fax | 727-797-4301
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Provider Business Mailing Address
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Address Line | 2350 SUNSET POINT RD STE C
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City | CLEARWATER
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State | FL
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Zip | 33765-1443
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Country | US
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Telephone | 727-797-3155
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Fax | 727-797-4301
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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 | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number | ARNP9204048
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License Number State | FL
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