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General NPI Number Information
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NPI Number | 1235637182
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Entity Type | Individual
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Provider Name | LISA M. WALLACE FNP
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Gender | Female
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Dates
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Enumeration Date | 01/25/2018
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Last Update Date | 02/24/2021
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Provider Practice Location Address
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Address Line | 800 E CHEVES ST STE 200
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City | FLORENCE
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State | SC
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Zip | 29506-2651
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Country | US
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Telephone | 843-662-1502
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Fax | 843-678-3611
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Provider Business Mailing Address
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Address Line | PO BOX 3239
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City | FLORENCE
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State | SC
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Zip | 29502-3239
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Country | US
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Telephone | 843-777-7098
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Fax | 843-777-7102
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 21595
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License Number State | SC
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