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General NPI Number Information
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NPI Number | 1629037676
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Entity Type | Individual
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Provider Name | MARLENE M.B. WALLACE CRNA
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Gender | Female
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Dates
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Enumeration Date | 03/20/2006
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Last Update Date | 02/13/2023
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Provider Practice Location Address
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Address Line | 5955 ZEAMER AVE 673RD MEDICAL GROUP/SGHQ DOD-VA JOINT VENTURE HOSPITAL
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City | JBER
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State | AK
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Zip | 99506-3702
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Country | US
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Telephone | 907-580-1035
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Fax | 907-580-3203
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Provider Business Mailing Address
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Address Line | 5955 ZEAMER AVE 673RD MEDICAL GROUP/SGHQ DOD-VA JOINT VENTURE HOSPITAL
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City | JBER
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State | AK
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Zip | 99506-3702
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Country | US
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Telephone | 907-580-1035
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Fax | 907-580-3203
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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 | 163WP0000X
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Taxonomy Name | Pain Management Registered Nurse
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License Number | 041305554
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 209012095
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License Number State | IL
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