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General NPI Number Information
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NPI Number | 1700531498
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Entity Type | Individual
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Provider Name | TONIA WALLACE PMHNP-BC
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Gender | Female
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Dates
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Enumeration Date | 02/21/2022
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Last Update Date | 11/20/2025
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Provider Practice Location Address
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Address Line | 6751 N SUNSET BLVD STE 320
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City | GLENDALE
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State | AZ
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Zip | 85305-3155
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Country | US
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Telephone | 480-516-8037
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Fax |
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Provider Business Mailing Address
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Address Line | 15652 W DURANGO ST
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City | GOODYEAR
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State | AZ
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Zip | 85338-3370
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Country | US
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Telephone | 708-829-1520
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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 | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 270985
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 5020892
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License Number State | NC
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