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General NPI Number Information
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NPI Number | 1356796262
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Entity Type | Individual
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Provider Name | TERRI WALLACE FNP
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Gender | Female
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Dates
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Enumeration Date | 04/28/2016
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Last Update Date | 07/18/2025
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Provider Practice Location Address
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Address Line | 1056 E RAINES RD
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City | MEMPHIS
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State | TN
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Zip | 38116-6337
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Country | US
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Telephone | 901-300-5777
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Fax | 901-422-6092
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Provider Business Mailing Address
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Address Line | 1056 E RAINES RD
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City | MEMPHIS
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State | TN
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Zip | 38116-6337
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Country | US
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Telephone | 901-300-5777
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Fax | 901-422-6092
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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 | 21186
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 21186
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License Number State | TN
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Taxonomy #3
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 904130
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License Number State | MS
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