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General NPI Number Information
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NPI Number | 1811393648
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Entity Type | Individual
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Provider Name | CYNTHIA WALLACE AGPCNP
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Gender | Female
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Dates
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Enumeration Date | 11/05/2014
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Last Update Date | 09/30/2020
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Provider Practice Location Address
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Address Line | 1111 CRATER LAKE AVE
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City | MEDFORD
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State | OR
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Zip | 97504-6241
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Country | US
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Telephone | 541-732-5250
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Fax | 541-732-5251
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Provider Business Mailing Address
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Address Line | PO BOX 3308
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City | PORTLAND
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State | OR
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Zip | 97208-3308
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Country | US
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Telephone | 541-732-5250
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Fax | 541-732-5152
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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 | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 201500016NP-PP
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License Number State | OR
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