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General NPI Number Information
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NPI Number | 1598356289
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Entity Type | Organization
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Legal Business Name | WALLACE HEALTH, LLC
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Dates
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Enumeration Date | 01/27/2021
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Last Update Date | 01/27/2021
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Provider Practice Location Address
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Address Line | 287 S CENTRAL AVE
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City | UMATILLA
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State | FL
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Zip | 32784-8411
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Country | US
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Telephone | 352-747-0747
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2485
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City | UMATILLA
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State | FL
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Zip | 32784-2485
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Country | US
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Telephone | 352-551-9404
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. COLLEEN WALLACE
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Credential | NP-C
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Telephone | 352-747-0747
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number |
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License Number State |
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