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General NPI Number Information
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NPI Number | 1558256594
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Entity Type | Individual
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Provider Name | TRENEICE WALLACE
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Gender | Female
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Dates
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Enumeration Date | 06/10/2025
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Last Update Date | 06/10/2025
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Provider Practice Location Address
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Address Line | 7487 S STATE ROAD 121 # A
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City | MACCLENNY
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State | FL
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Zip | 32063-5451
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Country | US
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Telephone | 904-330-2572
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Fax |
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Provider Business Mailing Address
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Address Line | 14511 MACADAMIA LN
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City | JACKSONVILLE
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State | FL
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Zip | 32218-1980
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Country | US
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Telephone | 954-607-8406
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Fax |
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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 | 163WP0809X
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Taxonomy Name | Adult Psychiatric/Mental Health Registered Nurse
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License Number | 9176588
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License Number State | FL
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