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General NPI Number Information
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NPI Number | 1801752449
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Entity Type | Individual
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Provider Name | KRISTAL LEANN WALLACE FNP-BC
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Gender | Female
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Dates
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Enumeration Date | 12/29/2025
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Last Update Date | 12/29/2025
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Provider Practice Location Address
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Address Line | 1851 OLD US 66
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City | EDGEWOOD
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State | NM
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Zip | 87015-7200
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Country | US
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Telephone | 505-286-2396
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Fax |
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Provider Business Mailing Address
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Address Line | 1839 BLACK GOLD ST SE
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City | ALBUQUERQUE
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State | NM
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Zip | 87123-2190
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Country | US
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Telephone | 602-373-4929
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 87084
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License Number State | NM
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