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General NPI Number Information
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NPI Number | 1457334633
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Entity Type | Individual
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Provider Name | WILLIAM S WALLACE FNP
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Gender | Male
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Dates
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Enumeration Date | 11/22/2005
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Last Update Date | 03/05/2010
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Provider Practice Location Address
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Address Line | 1200 PEABODY AVE
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City | MEMPHIS
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State | TN
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Zip | 38104-4506
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Country | US
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Telephone | 901-272-0003
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Fax | 901-272-7179
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Provider Business Mailing Address
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Address Line | PO BOX 41527
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City | MEMPHIS
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State | TN
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Zip | 38174-1527
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Country | US
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Telephone | 901-272-0003
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Fax | 901-272-7179
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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 | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 108204
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | RN108204
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License Number State | TN
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