=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689691115
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARGARET A WALLACE FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2006
-----------------------------------------------------
Last Update Date | 11/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1044 N MASON RD DEPT OTOLARYNGOLOGY, STE L20
-----------------------------------------------------
City | CREVE COEUR
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63141-6431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-362-7509
-----------------------------------------------------
Fax | 314-362-7522
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7412011
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60674-2011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-362-7509
-----------------------------------------------------
Fax | 314-362-7522
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 364S00000X
-----------------------------------------------------
Taxonomy Name | Clinical Nurse Specialist
-----------------------------------------------------
License Number | 073145
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 073145
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------