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General NPI Number Information
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NPI Number | 1730900648
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Entity Type | Organization
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Legal Business Name | ISLAND LIFE PERSONALIZED MEDICINE
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Dates
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Enumeration Date | 10/23/2024
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Last Update Date | 10/23/2024
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Provider Practice Location Address
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Address Line | 3817 GULF SHORES PKWY STE 9
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City | GULF SHORES
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State | AL
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Zip | 36542-2781
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Country | US
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Telephone | 251-842-4287
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Fax | 251-235-8232
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Provider Business Mailing Address
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Address Line | 3817 GULF SHORES PKWY STE 9
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City | GULF SHORES
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State | AL
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Zip | 36542-2781
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Country | US
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Telephone | 251-842-4287
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Fax | 251-235-8232
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Authorized Official
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Title or Position | NURSE PRACTITIONER
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Name | MAGGIE MAE WALLACE
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Credential | CRNP
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Telephone | 251-842-4287
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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