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General NPI Number Information
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NPI Number | 1851403257
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Entity Type | Individual
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Provider Name | LESHONDA TEQUILLA WALLACE FNP
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Gender | Female
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Dates
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Enumeration Date | 08/31/2006
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Last Update Date | 08/26/2025
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Provider Practice Location Address
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Address Line | 1725 NEW HANOVER MEDICAL PARK DR
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City | WILMINGTON
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State | NC
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Zip | 28403-5345
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Country | US
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Telephone | 910-662-9300
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Fax | 910-662-9301
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Provider Business Mailing Address
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Address Line | PO BOX 936857
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City | ATLANTA
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State | GA
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Zip | 31193-6857
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Country | US
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Telephone |
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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 | 5006194
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License Number State | NC
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