=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265357305
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLE WALLACE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2026
-----------------------------------------------------
Last Update Date | 08/10/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 450 HIGHLAND AVE
-----------------------------------------------------
City | MOUNT VERNON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10553-2109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-213-6552
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 450 HIGHLAND AVE
-----------------------------------------------------
City | MOUNT VERNON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10553-2109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-213-6552
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WW0000X
-----------------------------------------------------
Taxonomy Name | Wound Care Registered Nurse
-----------------------------------------------------
License Number | 882146
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------